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Hallux Limitus/Rigidus

Discussion in 'Biomechanics, Sports and Foot orthoses' started by podpaul, Mar 20, 2009.

  1. podpaul

    podpaul Active Member


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    Hello everyone,

    Looking for some advice. I have a patient who is in the transition from hallux limitus to hallux rigidus. The L/1st MTPJ is very painfull on movement, so my first thought was to restrict the movement here with a shaft pad added to an insole.

    Th problem is, that she is low gear propulsing to try and avoid wt bearing on the meidal forefoot and propulsing though the hallux. This is resulting in muscle pain on the dorsum of the foot and anterior leg. The problem is if i restrict motion through her 1st MTPJ I amm encouraging her into low gear propulsion which is going to increase her muscular pains.

    Any thoughts of how I can get around this would be greatfully recieved.

    Thanks

    Paul.
     
  2. Joe

    Joe Member

    Hi Paul,

    Usualy when pt's come into see me with painful hallux rigidus and a modified gait secondary to this condition, I recommend a forefoot rocker bottom on the shoe. This helps transfer weight from the MPJ's to toe off with alot less stress and ground reactive force. The rocker bottom should have some stiffness to it to decrease bending in the toe area of the shoe. If this is a modification that I apply to the shoe, I will add the same amount of material to the other shoe as not to create a LLD.

    Another option is try a running shoe that already has some good forefoot rocker built in and add a carbon footplate. Some footplates can be heat molded to the contour of the shoe.

    Hope this helps.


    Joe Eads, C.Ped
    Certified Pedorthist
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Why? What will that do, and what's the point?

    It is a strange phenomenom that we podiatrists persist in describing osteoarthritis (when it affects the 1st MTP joint) as some kind of mystical biomechanical entity that has its own unique characteristics. Osteoarthritis is osteoarthritis, wherever it occurs in the body. The same progressive pattern of osteochondral deterioration occurs, and the treatments are always exactly the same. If it hurts, splint (ie orthotic) the joint decrease extreme end ROM stresses, use simple analgesics, passive mobilisation (ie use it or lose it), or provide surgery (arthroplasty, arthrodesis, or joint replacement). Its the same deal in knees, ankles, hips, spines, wrists....etc.

    Say what? I personally feel your description above, though arugably correct is a symptom of the need in podiatry to overconceptualise what is a long understood clinical entity, and classic degenerative process. There really is little great need to understand about the why (other than obvious gross mechanical stress issues affecting the joint), and probably much more to learn about getting on with fixing this problem for the patient.

    Sorry if this sounds a bit harsh - it 5.45am and I havent had a coffee yet...:morning:

    LL
     
  5. Paul:

    Joe's idea of a rocker soled shoe is one idea that may allow this patient to walk with less pain. You could always try a clog or MBT shoe also that has a rocker sole built into it if the patient is dead-set against surgery. Icing the joint and NSAIDS are also helpful with these patients, in addition to possibly adding a rigid plate to the 1st MPJ are of the shoe to prevent shoe flexion at the 1st MPJ.

    In my practice, if the patient has pain with dorsiflexion of the hallux at the end range of motion of the 1st MPJ, I will first use an inverted custom foot orthosis with a Morton's extension. The inverted orthosis will cause the patient to walk with the foot supinated off the 1st MPJ and the Morton's extension will "lock up" the 1st MPJ enough so that dorsiflexion motion of the hallux is decreased which should make them much more comfortable when walking.

    However, most of these patients are eventually best-served with some form of 1st MPJ surgery to either decompress the 1st MPJ and remove the dorsal spur or to arthrodese the 1st MPJ. In my experience, 1st MPJ arthrodesis in the best long term solution for most patients with advanced DJD of the 1st MPJ, with a minimum of complications and gait sequellae, if the surgery is performed correctly.

    Hope this helps.
     
  6. podpaul

    podpaul Active Member

    Thank you all for your advice, it certainly gives me a few ideas.
     
  7. docstivers

    docstivers Welcome New Poster

    What usually works for me is to use a true forefoot post with one Quarter inch poron medialy and skived laterly to ground. This is added to an orthosis and extends to the sulcus also skived down distaly and proximaly on orthosis.This will cause normal gate in which push off is toward 5th toe to taking pressure off of first MPJ and very little dorsiflexion of hallux is needed.
     
  8. joejared

    joejared Active Member

    One of the doctors I work with requested a rocker heel designed into the orthotic as well, some years ago. First, they build the rocker heel into the orthosis, and afterwards back fill it with a softer material to further cushion the heel strike.
     
  9. jackboot

    jackboot Member

    Hi podpaul
    I agree with the advice to provide rocker soles to reduce the pressure on the MP1 joint. However, what I do first is to provide a insole in "detrosion" effect: 1. Forefoot pronation; 2. Rearfoot supination. Try, it works![​IMG]
     
  10. markjohconley

    markjohconley Well-Known Member

    good morning jack, bear with me as i haven't ventured into a podiatry thread for a while, .... had to google 'detrosion' and still don't understand, would you fill me in.... and wouldn't the forefoot valgus section of your insole promote the positive windlass so only further aggravate the pain?, thanks, mark
     
  11. I love you, Mark. Will you marry me?

    I think it's a standard protocol with reverse Morton's on the forefoot.
     
  12. Boots n all

    Boots n all Well-Known Member

    Rocker sole is the way l would go also, quick, cheap and it always work.

    This will give your client relative pain free time to think about surgery, as for an orthosis with rocker heel, not sure on the relevance or how it would even work?
     
  13. Mark:

    I believe in Germany and Switzerland the concept of "detorsion" means using a rearfoot varus wedge along with a forefoot valgus wedge on an orthosis. Maybe Jack can confirm this for us.
     
  14. Valerie

    Valerie Member

    Hi, your idea sounds similar to the cluffy wedge. Have you heard of this? I am a dom podiatrist and just wondered when you skive the posts do you do this yourself or can you order them to size ie small,medium, large. Thank you
     
  15. footdoctor

    footdoctor Active Member

    Valerie,

    a cluffy wedge extends from the sulcus to the end of the hallux,thickening from the proximal phalanx to end of digit. It is designed to preload the hallux.this is not the same as a forefoot varus post with a poron extension to sulcus. Preloading the hallux in a joint with degenerative changes is contraindicative I wound think?

    Scott
     
  16. Valerie

    Valerie Member

    Thank you for your comments which I appreciate. I am a novice in this area. I read an article by James Clough (inventor of the cluffy wedge) about the diagnosis and treatment of functional hallux limitus in which he discusses first ray cut out and reverse mortons extension but wonders whether these orthoses could delay resupination of the foot in propulsion. I am just trying to figure out the best way forward for me, who often uses chair side orthotics. I do not know how to skive (except when I was at school). How would I fashion such an orthotic? Thank you so much for your help. I notice you are a senior memeber.
     
  17. footdoctor

    footdoctor Active Member

    Glad to help Valerie.

    The post/discussion was based around the treatment for structural hallux limitus/rigidus though and not functional hallux limitus. Treatment for the two conditions is different. I dont think that a reverse mortons extension (in combination with an functional foot orthotic designed to decrease the external stj pronatory moment) is likely to delay resupination of the foot either. If the GRF sub 1st mtpj is reduce, windlass function is optimised which will likely allow resupination at the propulsive phase of gait.
    As for skiving. do you mean medial heel skive? If you would like more information about the medial heel skive technique I suggest that you read the original paper from JAPMA by Dr Kevin Kirby.I believe that he may have posted a link to the paper previously on this site.
    Dont be afraid to ask questions, its how we learn.

    Scott
     
  18. Bruce Williams

    Bruce Williams Well-Known Member

    Scott;
    your quote, "If the GRF sub 1st mtpj is reduce, windlass function is optimised which will likely allow resupination at the propulsive phase of gait."

    This is incorrect. The pressure and force sub 1st mpj should increase after the heel has lifted and slightly before hallux pressure and force has increased. It is the timing of the increase in pressure and force that makes the difference here.

    If the hallux extends the metatarsal will have in increase in force and pressure and the windlass / plantar fascia tension will increase in a way that supinates the rearfoot towards the forefoot. You have a pronated foot position with a supinated STJ in the best of cases.

    I hope this clarifies things more than confuses them.
    Cheers
    Bruce
     
  19. footdoctor

    footdoctor Active Member

    Bruce,

    Would I be incorrect in saying that excessive GRF sub 1st mtpj is the primary aetiological factor contributing to a functional limitation of hallux dorsiflexion in the propulsive phase of gait? By excessive I mean more force than is required.

    Cheers

    Scott
     
  20. Bruce Williams

    Bruce Williams Well-Known Member

    I would have to say yes. My in-shoe pressure experience, and I think others on this list as well, would point to the fact that FnHL is highly associated with a decrease in sub 1st mpj plantar pressures.

    Again, while I know pressures adn forces are not the same, I do not think they are mutually exclusive either. And, I am talking functional pressure mapping, not static stance. That is somewhat different.

    Eric Fuller has said that the primary force that creates FnHL is from the windless, but the force is within the mpj, not under it. I would tend to agree with him.

    You must understand that there is much going on to create this scenario, ie: DFion stiffness of the metatarsals, AJE, STJ pronation, MTJ compensation, plantar fascia tendsion, decrease in hip extension, LLD, muscle forces changed from inhibition or prolongation of activation and other potential cns effects. All in some form of combination.

    cheers
    Bruce
     
  21. footdoctor

    footdoctor Active Member

    thanks for your reply Bruce.

    is it not more a case of optimal (whatever that is) sub 1st pressure?

    Too low a force sub 1 = delayed windlass

    Too much pressure sub 1= more force required to dorsiflex hallux.

    With patient seated, Apply a d/fory force plantar 1st met, then try and dorsiflex the hallux, its requires more force right?

    sorry if i'm having a slow sunday.

    Yes totally agree that it is multifactoral.

    cheers

    scott
     
  22. Bruce Williams

    Bruce Williams Well-Known Member

    Scott;

    too much pressure sub 1 will not require more force to dorsiflex the hallux. Usually these patients have a high DFion stiffness of the mets at least 2-5 and a very high arched stable midfoot / Rearfoot complex. Sometimes they have a PF'd 1st ray. That inherent positioning already has the hallux DF'd in relation to the 1st metatarsal.

    You are confusing your exapmles of non-weight bearing testing and actual functional mechanics. They are not completely the same. In reality what you are doing with the FnHL test is DFing the 1st ray, elongating the PF and driving the force inward at the 1st mpj and not SUB 1st mpj!

    Bruce
     
  23. footdoctor

    footdoctor Active Member

     
  24. Bruce Williams

    Bruce Williams Well-Known Member

     
  25.  
  26. footdoctor

    footdoctor Active Member

    Thanks Kevin and Bruce

    I understand now.


    Reduced d/f stiffness of 1st ray

    D/f of 1st ray/medial column on loading.

    Increase in tensile stress within plantar fascia

    Increase in 1st mpj p/f moment

    Increase in GRF sub hallux, NOT PLANTAR 1st MET. THIS IS WHERE I WAS GOING WRONG

    Reduced d/f of hallux in propulsion.

    So its really an issue of increased internal forces yeah?


    Thank you both for your help.

    Scott
     
  27. efuller

    efuller MVP

    In my windlass paper I predicted that high force under the first ray would cause an increase in dorsiflexion stiffness. Bruce has seen a decrease in force under the first metatarsal head with functional hallux limitus. This descrepency can be resolved if we define first ray load from ground reaction force as load under the 1st met head and hallux. With a functional hallux limitus you will see shoe impressions that are very deep under the hallux and often moderately deep under the met head. My explanation for this is that at heel lift, the geometry created by a temporarily rigid 1st MPJ (functional hallux limitus) will create a long rigid lever that pivots over the tip of the toe and not at the met head. When this happens you will see decreased forces at the met head and increased forces on the hallux. (Think of the classic hallux "pinch callus"). This is also consistent with the observation when the patient is in the chair an you push upward on the met and try to dorsiflex the hallux. It will be harder to dorsiflex the hallux the more force is applied to the metatarsal head.

    Regarding the internal forces at the MPJ causingj increased stiffness of the 1st MPJ. In gait, at heel lift, the ground will be causing a dorsiflexion moment at the 1st MPJ. To prevent motion there must be an internal plantarflexion moment. This moment comes from tension in the fascia and compression at the MPJ joint surfaces. With pronation of the STJ and dorsiflexion of the first ray there will be an "unwinding of the windlass" that will create that internal plantar flexion moment at the first ray.

    I hope this helps.

    Eric
     
  28. Joe

    Joe Member

     
  29. jackboot

    jackboot Member

    Detrosion in our unterstanding means:
    - rearfoot supination (medial arch support)
    - forefoot pronation (lateral thiker than medial)[​IMG]

    @markjohconley
    I don't unterstand the expression "positive windlass". What does it stand for?
     
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