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I had a conversation this morning with a very experienced Podiatrist regarding the use of a toe spreader for patients with mild hallux abducto valgus. I usually have patients who present to the clinic with the usual hallux abducto valgus condition, where the displacementt of the hallux has underridden the 2nd digit, and has made the 2nd digit progress to an evident hammer toe condition.
My question to my experienced colleague was to know if he was in favor of using a gel toe spreader in conditions such as the one described above to help keep the halux in its normal position and decrease the presure caused on the lesser digits, especially the 2nd digit.
He explained to me that he is against the use of gel toe spreaders where the hallux is concerned as he feels that the hallux will still press on the toe spreader and the toe spreader itself will continue to cause further lateral deviation of the lesser toes.
I had a conversation this morning with a very experienced Podiatrist regarding the use of a toe spreader for patients with mild hallux abducto valgus. I usually have patients who present to the clinic with the usual hallux abducto valgus condition, where the displacementt of the hallux has underridden the 2nd digit, and has made the 2nd digit progress to an evident hammer toe condition.
My question to my experienced colleague was to know if he was in favor of using a gel toe spreader in conditions such as the one described above to help keep the halux in its normal position and decrease the presure caused on the lesser digits, especially the 2nd digit.
He explained to me that he is against the use of gel toe spreaders where the hallux is concerned as he feels that the hallux will still press on the toe spreader and the toe spreader itself will continue to cause further lateral deviation of the lesser toes.
In my humble opinion it is unlikely the gel toe spreader will realign the hallux. Causation of HAV is too complex and arises usually more proximal in the foot. Neither will it case further deviation for the same reason.
There is a natural gap between toe 1and 2 and toe 4 and 5 and the musculature in the medial; and lateral toes 1 an 5 are independent of toes 2,3 and 4; albeit there is some cross over. This would support the theory the middle three toes should lie parallel to each other with minimum gaps between them. Obviously in the case of subluxation the middle toes do err and gaps may appear. I still prefer to prop these together and use silicone putty to this end. The 'natural' gaps between toes 1/2 and 4/5 I will fill as end pieces for the toe prop.
The beneifit of viscoelastic seperators (either as individual toe spacers or lugs for toe props ) is the material takes up an intrinsic shape of the opposing digits. Like a water bed effect this will increase the surface area between the digits thereby reducing the effects of joint grinding forces present that may cause interdigital lesions. Spreading force over a wider surface area results in reduced pressure and the physical properties of the gel may also help reduce shear. The gels are superior to traditonal cellular and or felt padding to this end.
The toe seperator alone will not significantly realign the big toe position although its presence can be a comfort - to that end the application is purely palliative. Toe props which have toe spacers 1/2 and 4/5 plus the prop under toes 2.3 and 4 will
assist toe function by increasing ground contact during propulsion. Arguably this may result in anti-pronatory moments during heel lift to the beginning of swing phase. The resultant increased muscle tone to the intrinsic muscle may account for the physical changes in the toe positon of the middle three toes which appear to result when wearing serial silione toe props. In any event ortho-digital therapy is unlikely to influence the positon of HAV.
I use some form of interdigital wedge/toe separator wherever footwear will accommodate it.
The reasoning is simple. It is not designed to fix the HAV, but to slow the progression through a simple buttress effect.
This is best exemplified by looking a digital amputations. Whenever a toe is amputated, the others will ab/adduct to "fill the void". Net digital deformity increases.
So too with HAV. If the hallux is given no resistance in the transverse plane, then the deformity accelerates along with the flow on effect to the lesser toes .
Whilst there are some forces transmitted in the transverse plane to other lesser toes from the use of such wedges, I think this needs to be balanced with the degenerative issues that HAV causes at the 1st MTP and 2nd toe.
Just my approach.
LL
__________________
***************************************** Remember, it's just a foot.
Thank you very much for your replies. I may have given the impression that my intention for using a hallux toe spreader was to realign the hallux with its use. This is not what I wanted to say. What I wanted to say was that having a deviated hallux which is causing 2nd toe displacement, by using the toe spreader (in mild cases) I am able to straighten the hallux while the toe spreader is in place. obviously once the toe spreader is removed the hallux gors back to its deviated position under riding the 2nd toe in this case.
I presume that even regarding Night HAV splints it is the same situation where many practitioners do not feel that these HAV night splints do any work on the HAV joint, although some practitioners say that Night HAV splints may in certain cases help decrease progression of the HAV condition.
Again if you have time would appreciate your opinion.
An alternative approach that I have used successfully several times in this situation is to form an orthodigital silicone pad over the proximal dorsum of the 2nd toe, retained by thin 'legs' that descend between 1/2 and 2/3. The silicone block makes contact with the inner toe box and depresses the 2nd toe into line with the other lesser digits. This improves the alignment of the hallux and the 2nd toe then holds the hallux out so that it cannot make progress into the space that should be occupied by the lesser digits.
If you can accept that a healthy first MPJ should work primarily in the sagittal plane, you will appreciate that HAV is a frontal plane deformation. Night splints push the hallux medially every night and diurnal forces push the hallux laterally by day. The night splint adds to the pathological frontal plane joint range and usage and can only advance the joint pathology in the long term.
Firstly, I rarely advocate my patients using interdigital toe wedges in the management of hallux valgus. I think if the hallux is going to deviate laterally, then putting something between it and the adjacent 2nd toe is not going to affect the progression of the deformity.
Secondly, I think it is important to consider what actually causes deformity/deviation of the 2nd toe. My understanding is that the integrity of the plantar plate of the 2nd MTPJ will have a significant influence on the position/alignment of the 2nd toe. I believe overloading of the 2nd MTPJ and subsequent attenuation or rupture of the plantar plate is a more significant factor in 2nd toe mal-alignment than the actual pressure of the hallux against the 2nd toe.
I am currently looking at surgical outcomes following 2nd MTPJ plantar plate repair so maybe i focus too much on this?
I remember a previous post in which Kevin Kirby reminded me that not all plantar plate tears need repairing. He compared this to ATFL tears. This has always stuck with me so I continually trying to be careful not to focus so much on this and I do appreciate that this is not the only contributing factor to the original pathology described.
Rambled on a bit there but those are my thoughts.
Ryan
Last edited by Ryan McCallum : 1st February 2009 at 06:01 AM.
Reason: Typo
Hi Ryan:
"I am currently looking at surgical outcomes following 2nd MTPJ plantar plate repair..............."
Can you expand on this for us?
Thanks
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Hi Steve,
I have recently started my surgical training in the UK and as part of this, I need to have published a paper at the end of it.
My tutor lectured on this procedure recently and had suggested that I look retrospectively at 1-2 year outcomes with patients who have had plantar plate repair of the 2nd MTPJ. I think this is a procedure that he has performed in the past then stopped and now started doing again. It seemed like a worthwhile subject to do my paper on and I hope to find out whether or not this is a worthwhile procedure to carry out. In my short time working in the unit, I get the impression that the result is usually of a stiff, elevated toe but most patients seem happy.
I have only recently started trying to gather together the patients and so have little information to be honest so far. Formal follow ups have not yet started as I still have quite a bit of planning to do. Have an exam in March and so this has had to take a back seat for the meantime.
Basically, the patients will have had an arthrodesis of the 2nd PIPJ in conjunction with the repair for lesser MTPJ sagittal plane instability. It seems most (again, very early days so I could be wrong) have had hallux valgus correction at the same time.
I intend to look at clinical and radiographic alignment/position of the toe (will not be looking at outcome of hallux valgus correction), whether or not the toe purchases the ground, how the toe functions and also patient satisfaction.
I apologise for the lack of detail. I intend to plan much more of this in greater detail after the exam.
Thanks. It sounds very interesting. Good luck to you.
In my own small world I have found very poor results in simply repairing any tears in the plate with or without additional digital procedures. I have found that most, if not all of these patients have an elongated and / or plantar flexed 2nd metatarsal (regardless of the underlying REASON for this).
As such I began performing shortening osteotomies on these patients (with or without transverse plane correction) and have been getting very very good results. They do take some time to heal though.
Please let us know what you find. I guess we have to wait a year!
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Secondly, I think it is important to consider what actually causes deformity/deviation of the 2nd toe. My understanding is that the integrity of the plantar plate of the 2nd MTPJ will have a significant influence on the position/alignment of the 2nd toe. I believe overloading of the 2nd MTPJ and subsequent attenuation or rupture of the plantar plate is a more significant factor in 2nd toe mal-alignment than the actual pressure of the hallux against the 2nd toe.
I agree that it is important to consider what causes the deformity. It is also important to consider the first MPJ as well. The hallux deviates toward the second because of the "buckling phenomenon". A plantar flexion moment on the hallux has been shown to increase the promence of the first met head medially. In my Windlass paper I describe the forces involved in the buckling. When the force from the plantar fascia or FHL muscle is not directly alligned with the center of pressure at the Met head then the hallux will tend to rotate in the transverse plane. If the forces are misalignged one way you get an abduction moment on the hallux and when misaligned the other way you will get an adduction moment on the hallux. The hallux will move when the deforming moment is greater than the restraining moment. The collateral ligaments at the joint will provide the restraining moments. When the hallux hits the second toe, or a spacer between the first and second toe there will be additional moment resisting adduction of the hallux. The deforming moment will increase when the distance between the rearward pull (from fascia or tendon) and the force from the met head acting on the phalanx are farther apart. (This is a classic force couple where moment is equal to force times distance.) So, the further the deviation of the hallux, the increased likelihood of increased adduction moment from the position of the forces. (The forces may decrease, so this not the only factor.)
So, a case can be made that a spacer can impede the progression of bunion deformity by keeping the toe in better alignment and the deforming moment is smaller and the resisting moment produced by the 2nd toe can be smaller.
With an advancing bunion, the hallux applies a force to the second toe that would tend to move the 2nd toe, at the MPJ, in the frontal plane toward the fifth toe. This moment will be resisted by the collateral ligament and joint compression forces at the MPJ. Whether or not the second toe moves in response to these depends on whether the moment causing deformity is greater than the moment resisting deformity.
So, if a spacer reduces the force from the hallux on the second toe, by decreasing the deforming moment on the hallux a case could be made that the spacer would reduce the deforming forces on the second toe.
There are many assumptions in the above. One assumption is that the collateral ligament of the 2nd mpj will not elongate in the presence of small forces as opposed to large forces.
E:
On the other side of the argument, how often do you see normal ROM in dorsiflexion in a clinical hallux valgus but when you manually force the toe it in rectus and try to dosiflex it the ROM is not only decreased but painful as well.
Reason? With the first met adductus and hallux valgus you "usually" have a subluxed but congruous joint (meaning that the joint space is symmetrical even though the adjacent surfaces are not aligned).
If you merely force the toe in rectus but leave the metatarsal in adductus what you are doing is jamming the medial side of the 1st MTPJ and making it incongruous - causing mechanical friction and decreased ROM in this joint. In my humble opinion this accelerates any degenerative process of the MTPJ.
When patients with HAV ask about spacers I often perform this maneuver, i.e., place the toe in rectus, load the foot and reproduce dorsiflexion at the 1st MTPJ. It never feels good to them.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
I have analyzed its question on the gel separators use in patients with hallux valgus.
The answer of its above-mentioned colleague to the increase of abduction in the smaller fingers is frequently wise.
I should do some appreciations, which invite to consider:
• The use of ortesis digital prefabricated is not very acceptable upon originating pressures unbalanced in the space interdigital.
Perhaps upon being of gel this problem has a smaller importance, but would be desirable that in all the cases be to preferred an ortesis digital personalized, concocted with silicone of medical degree, and adapted directly in the foot of the patient.
• If we intend to appreciate which can be the corrector utility of this ortesis, suffices with placing a standard separator in the space interdigital and to observe if improves the position of the hallux, or as is more frequent, abduce the fingers media.
• In the case to improve the position of the hallux, the following and indispensable step would be to value the footwear that uses the patient.
If this footwear does not permit that the first finger remain well aligned, this obliges a sure increase of the power abductor on the fingers media.
This problem is greater in the female footwear, therefore too often has the tip badly designed, motive by which in my country I practice many surgeries of hallux valgus in women and very few in men.
To educate the patients on the acquisition of footwear, he suffices with catch together the shoes to value, and to observe the distance among his tips. To greater distance, more deformity; and to smaller distance, these if that would improve the evolution of the deformity and they would be able to accept the inclusion of an ortesis.
• In my experience I have verified that to use a separator, improvement the pain in the sharp phase.
Also it is useful to avoid that the first and second finger they overlap, motive of a serious acceleration of the deformity.
Finally especially it is indicated before the apparition of helomas interdigitales, although in these cases they should not reduce the deformity, only standardized the pressures in the space interdigital and to avoid the friction of the fingers during the march with footwear closed.
• I Coincide with the Dr. S Arbes, therefore if the deformity of the hallux valgus this structured, upon forcing the articulation without correcting the P.A.S.A., to use a separator accelerates without doubt the degenerative process of the cartilage to articulate.
I expect to have been useful.
Attentively:
Jose Antonio Teatino
Professor of Surgery
The Academy of Ambulatory Foot & Ankle Surgery
E:
On the other side of the argument, how often do you see normal ROM in dorsiflexion in a clinical hallux valgus but when you manually force the toe it in rectus and try to dosiflex it the ROM is not only decreased but painful as well.
Reason? With the first met adductus and hallux valgus you "usually" have a subluxed but congruous joint (meaning that the joint space is symmetrical even though the adjacent surfaces are not aligned).
Hi Steve,
For me, there are different reasons to recommend a spacer. I have a guy with diabetic neuropathy who when he walks a lot gets a blister on his second toe where the first rubs it. He loves his spacer and it prevents the blister. I certainly won't recommend it for joint pain related to a bunion. I'll bet there are some patients who can use a spacer where it will decrease their symptoms rather than increase. It's a cheap treatment that a patient can discard easily if it does not help. Also, some spacers could help prevent the over- or under- riding second toe. When you get crossed toes shoe options are decreased.
Quote:
Originally Posted by drsarbes
If you merely force the toe in rectus but leave the metatarsal in adductus what you are doing is jamming the medial side of the 1st MTPJ and making it incongruous - causing mechanical friction and decreased ROM in this joint. In my humble opinion this accelerates any degenerative process of the MTPJ.
Joint congruity is a concept that I've always had trouble with. It's often taught as if it's only about the joint surfaces. The collateral ligaments are important in the feeling of "congruity". When the joint is forced in one direction in the transverse plane joint motion will be limited by tightness in one of the colateral ligaments and increased joint compresion forces on the other side of the joint (a force couple creating an opposing moment to the externally applied moment.)
I agree that increased compresive forces at a time when the joint moves will increase the propensity for DJD. (I saw a cite to that effect once, I'll have to dig it up.) However, the transverse plane forces from a spacer are small in comparison to the flexion forces from the fascia and FHL tendon. How big of a spacer are we talking about? Yes, you can make a spacer big enough so that it hurts, but some of the time it may help.
Quote:
Originally Posted by drsarbes
When patients with HAV ask about spacers I often perform this maneuver, i.e., place the toe in rectus, load the foot and reproduce dorsiflexion at the 1st MTPJ. It never feels good to them.
Steve
The load from the spacer may be different from the load that you apply in the chair. Why not let the patient decide if the spacer works for them. There's an easy study for somebody. Dispense spacers to different 1st MPJ problems and then survey them for improvment. I don't really have a good idea of how many peope would be helped by spacers. I know that it is more than zero.
Hi Eric:
Good points.
I never argue success. If you have patients with heloma molle's in the first interspace and a spacer helps...pad on.
You are right about the clinical maneuver I mentioned; loading the toe in adduction and dorsiflexing it. In all fairness to both of us, it would be a difficult thing to quantify. On a qualitative level, I think it proves my point.
Some of this may also come own to "Hammer & Nail."
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Dear Eric and Steve:
I believe that you continue defending the prefabricated separator.
In my experience, to make a separator customized only needs seconds of my time, and the result is not comparable.
I invite to them to that they experiment to be able to continue growing, increasing therefore the well-being of its patients.
This certainly will be able to make them podiatras more complete and happy.
A warm greeting:
Jose Antonio Teatino
Professor of Surgery
The Academy of Ambulatory Foot & Ankle Surgery
I am wondering if there's any research or opinions out there on using targeted foot exercises, with or without toe separators to help improve hallux alignment? So that perhaps the muscles of the feet can become stronger to help hold the bones in better alignment.
I am wondering if there's any research or opinions out there on using targeted foot exercises, with or without toe separators to help improve hallux alignment? So that perhaps the muscles of the feet can become stronger to help hold the bones in better alignment.
Look forward to your thoughts and opinions!
Thanks,
Aliesa George
Hi Aliesa,
I always had trouble with the "muscle imbalance" theory of bunion formation. That is that the adductors pull harder than the abductors and this causes the bunion. Then one day I tried on a pair of shoes that were pointy and irritated the medial aspect of my hallux. I felt like I was trying to pull my toe away from the shoe all day long. I could see that being the cause of the "imbalance" and also that being the reason that you tend to see more bunions in shod populations.
So, to answer your question, you could try to teach someone to use their hallux abductors more, but it wont' do any good if there is no room in the shoe to abduct the toe.
Toe spreader for hallux allignment
Linear Mode
