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At several recent conferences conflicting data has been presented on the effects of foot orthoses on first MPJ motion. Opinioned varied as to why, but it was most likely due to differences in the material and shape of the orthoses under the medial column. We had this previous thread on Foot pronation and 1st MPJ motion.
To add to this body of knowledge, we now have this single subject design study: The influence of two different types of foot orthoses on first metatarsophalangeal joint kinematics during gait in a single subject.
Michaud TC, Nawoczenski DA. J Manipulative Physiol Ther. 2006 Jan;29(1):60-5
Quote:
OBJECTIVE: To quantify the effect of two distinct foot orthotic designs on in vivo multisegment foot and leg motion; in particular, the first metatarsal and first metatarsophalangeal (MTP) joint during gait.
METHODS: A 23-year-old man had an excessively pronated foot structure as measured during a clinical orthopedic examination. The Optotrak Motion Analysis System was used to collect three-dimensional position and orientation data from four modeled rigid body segments (hallux, first metatarsal, calcaneus, and tibia) during the stance phase of walking. The subject walked at a self-selected comfortable walking speed, and a minimum of five trials were collected under three different test conditions: no orthosis, semirigid orthosis with a varus post, and a semirigid orthosis with a varus post and a large medial flange. Data were normalized to the stance period, and descriptive statistics were calculated for dependent variables.
RESULTS: Both orthotic interventions equally modified first MTP joint motion when compared with the no orthotic condition. First MTP joint dorsiflexion was decreased (>2 SD) with the orthosis during terminal stance phase. This decrease was associated with a concomitant increase in first metatarsal plantar flexion.
CONCLUSION: A custom-made semirigid orthosis posted medially and made from a neutral position off-weight-bearing plaster cast can alter motion in the forefoot during the propulsive period by increasing first metatarsal plantar flexion and decreasing excessive first MTP joint dorsiflexion.
I know there can only be a small number of variables to a study but when these rearfoot control-1st mpj r.o.m tests are done there is no mention of 1st ray cast modification,terminal point of distal orthotic plate i,e bisection of 1st met head,or 1st/2nd interspace.etc Also 1st met or ray cut out?
If an orthotic in designed with a 4 degree varus post on the rearfoot,medial skive and medial flange you would naturally assume that the pronation moment will decrase and the supinatory moment in midstace will increase thus freeing up the 1st mpj to plantarflex and the halux to dorsiflex.Increasing the R.O.M at the mpj in the propulsive phase.
However if one of the following occured the 1st mpj R.O.M would be inhibited and reduced.
1)What position was the hallux in during casting?
2)How much plaster fill was added to to distal aspect of the 1st ray.
3)Was a forefoot supinatus mistaken for a forefoot varus and cast balanced inappropriately?
4)Where did the medial distal tip of the orthotic finish?
5)Was the distal medial aspect of the 1st ray portion of the orthotic ground down for asthetics(this would increase shell flex)
6)Was the shell thickness related to the patients weight?
Compare two devices.1)Rearfoot varus posted,medially skived,large medial flange,minimum arch fill proximally deep fill from forefoot balance platform extending the length of the 1st met shaft. Distal medial tip finishing 10 mm proximal to the 1st met head bisection and transversely between met 1 and 2
2) Rearfoot varus posted,medial skive,large medial flange,no arch fill.Orthotic shell finishing medial to the 1st met bisection and directly below the met bisection with little reverse bevelling of distal edge.
The difference would be minimal from heel strike to early mid stance but as device two had no plaster arch fill to the 1st ray and the medial tip finished too high and too medial 1st met plantarflexion would be reduced and hallux dorsiflexion reduced also.
Surely to have any true validity the exact deign of the orthotic device must be taken into consideration!
Perhaps this would make an interesting experiment,That is if it hasnt been done already.
I know there can only be a small number of variables to a study but when these rearfoot control-1st mpj r.o.m tests are done there is no mention of 1st ray cast modification,terminal point of distal orthotic plate i,e bisection of 1st met head,or 1st/2nd interspace.etc Also 1st met or ray cut out?
If an orthotic in designed with a 4 degree varus post on the rearfoot,medial skive and medial flange you would naturally assume that the pronation moment will decrase and the supinatory moment in midstace will increase thus freeing up the 1st mpj to plantarflex and the halux to dorsiflex.Increasing the R.O.M at the mpj in the propulsive phase.
However if one of the following occured the 1st mpj R.O.M would be inhibited and reduced.
1)What position was the hallux in during casting?
2)How much plaster fill was added to to distal aspect of the 1st ray.
3)Was a forefoot supinatus mistaken for a forefoot varus and cast balanced inappropriately?
4)Where did the medial distal tip of the orthotic finish?
5)Was the distal medial aspect of the 1st ray portion of the orthotic ground down for asthetics(this would increase shell flex)
6)Was the shell thickness related to the patients weight?
Compare two devices.1)Rearfoot varus posted,medially skived,large medial flange,minimum arch fill proximally deep fill from forefoot balance platform extending the length of the 1st met shaft. Distal medial tip finishing 10 mm proximal to the 1st met head bisection and transversely between met 1 and 2
2) Rearfoot varus posted,medial skive,large medial flange,no arch fill.Orthotic shell finishing medial to the 1st met bisection and directly below the met bisection with little reverse bevelling of distal edge.
The difference would be minimal from heel strike to early mid stance but as device two had no plaster arch fill to the 1st ray and the medial tip finished too high and too medial 1st met plantarflexion would be reduced and hallux dorsiflexion reduced also.
Surely to have any true validity the exact deign of the orthotic device must be taken into consideration!
Perhaps this would make an interesting experiment,That is if it hasnt been done already.
scott
Scott:
These are all good points. Until researchers are much more specific regarding exact orthosis design prescription variables and patient selection criteria for those orthosis design variables, clinicians will need to continue to rely on trial and error and theory in regards to the mechanical effects of the thousands of orthosis design permutations that are available to them for their patients.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Effect of Foot Posture and Inverted Foot Orthoses on Hallux Dorsiflexion
Shannon E. Munteanu and Adam D. Bassed J Am Podiatr Med Assoc 2006;96 32-37
Quote:
A pronated foot posture is considered to be a factor in limitation of dorsiflexion at the first metatarsophalangeal joint during weightbearing. Customized foot orthoses are widely used to increase dorsiflexion at the first metatarsophalangeal joint in people with pronated feet. However, the effect of foot posture and customized foot orthoses on maximum first metatarsophalangeal joint dorsiflexion has not been widely investigated. This study sought to determine 1) the relationship between foot posture and static maximum first metatarsophalangeal joint dorsiflexion and 2) the effect of customized foot orthoses on static maximum first metatarsophalangeal joint dorsiflexion in people with pronated feet. Foot posture was assessed using the Foot Posture Index. Static maximum first metatarsophalangeal joint dorsiflexion of the right foot was determined using a goniometer while participants stood relaxed with and without Blake-style inverted (30°) foot orthoses positioned under their feet. There was a significant negative correlation between Foot Posture Index and static maximum first metatarsophalangeal joint dorsiflexion (r = –0.587). Inverted (30°) foot orthoses increased the magnitude of static maximum first metatarsophalangeal joint dorsiflexion from 83.4° to 85.3° in participants with an excessively pronated foot posture. However, this difference was not statistically significant. People with pronated feet are more likely to exhibit limitation of dorsiflexion at the first metatarsophalangeal joint during gait, and inverted foot orthoses are unlikely to be effective in increasing dorsiflexion at the first metatarsophalangeal joint in these people. (J Am Podiatr Med Assoc 96(1): 32–37, 2006)
All,
In our study the dynamic effects of 5° varus and valgus rearfoot wedging on peak hallux dorsiflexion were investigated in 30 asymptomatic subjects (5 males and 25 females). Statistically significant reductions in peak hallux dorsiflexion were found with rearfoot varus wedging and rearfoot valgus wedging. Furthermore, the reduction in peak hallux dorsiflexion occurring with rearfoot varus wedging was statistically significant compared with that associated with rearfoot valgus wedging. (J Am Podiatr Med Assoc 94(6): 558–564, 2004)
The aim of this study was to determine whether the treatment of abnormal subtalar pronation restores functional (as opposed to structural) limited dorsiflexion of the first metatarsophalangeal joint (functional hallux limitus). We studied 16 feet of eight individuals with abnormal subtalar pronation. Orthoses were made for all of the feet, and hallux dorsiflexion was measured during weightbearing. Each patient was unshod without the orthosis, unshod with the orthosis fitted on the same day, and unshod with the orthosis fitted approximately 5 months later. The results suggest that in functional hallux limitus caused by abnormal subtalar pronation, hallux dorsiflexion will gradually be restored by the use of foot orthoses to control the abnormal subtalar pronation.
This study was conducted to determine whether navicular drop, as a representative measure of foot pronation, was associated with first metatarsal joint motion in 24 healthy subjects aged 21 to 40 years. The magnitude of first metatarsophalangeal joint motion was identified using a custom-built weightbearing goniometer designed to measure maximal hallux dorsiflexion in stance. The weightbearing measure of navicular drop was recorded using an adapted digital caliper. Statistical analysis demonstrated a significant negative correlation (P < .05) between the two variables. Furthermore, simple regression analysis suggested that 33.2% of the variation in maximal hallux dorsiflexion could be explained by different navicular drop values.
Weight-Bearing Passive Dorsiflexion of the Hallux in Standing Is Not Related to Hallux Dorsiflexion During Walking
J. Halstead, A.C. Redmond
Study Design: Case control study.
Objective: To explore the validity of the assumptions underpinning the Hubscher maneuver of hallux dorsiflexion in relaxed standing, by comparing the relationship between static and dynamic first metatarsophalangeal (MTP) joint motions in groups differentiated by normal and abnormal clinical test findings.
Background: Limitation of motion at the first MTP joint during gait may be due to either structural or functional factors. Functional hallux limitus (FHL) has been proposed as a term to describe the situation in which the first MTP joint shows no limitation when non-weight bearing, but shows limited dorsiflexion during gait. One clinical test of first MTP joint limitation during standing (the Hubscher maneuver or Jack’s test) has become widely used in physical therapy, orthopedic, and podiatric assessments, supposedly to assess for the presence of hallux limitations during gait. The utility of the test is based on an assumption that restriction during the static maneuver is predictive of functional limitation at this joint during gait. Despite a lack of evidence for the validity of such an assumption, the outcome of the static test is often used to infer risk of overuse injury or as an outcome for functional therapy. This paper examines the validity of the assumptions supporting this widely used static test.
Methods and Measures: First-MTP-joint motion was assessed using an electromagnetic motion tracking system in cases (n = 15) demonstrating clinically limited passive hallux dorsiflexion in relaxed standing, and in 15 controls matched for age and gender and demonstrating a clinically normal Hubscher maneuver. Maximum hallux dorsiflexion was measured with the subject non-weight bearing (seated), during relaxed standing, and during normal walking.
Results: Hallux dorsiflexion was similar in cases and controls when motions were measured non-weight bearing (cases mean ± SD, 55.0° ± 11.0°; controls mean ± SD, 55.0° ± 10.7°), confirming the absence of structural joint change. In relaxed standing, maximum dorsiflexion was 50% less in cases (mean ± SD, 19.0° ± 8.9°) than in the controls (mean ± SD, 39.4° ± 6.1°; P<.001), supporting the initial test outcome and confirming the visual test observation of static functional limitation in the case group. During gait, however, cases (mean ± SD, 36.4° ± 9.1°), and controls (mean ± SD, 36.9° ± 7.9°) demonstrated comparable maximum dorsiflexion (P = .902). There was no significant relationship between static and dynamic first MTP joint motions (r = 0.186, P = .325).
Conclusion: The clinical test of limited passive hallux dorsiflexion in stance is a valid test only of hallux dorsiflexion available during relaxed standing. There is no association between maximum dorsiflexion observed during a static weight-bearing examination and that occurring at the same joint during walking. J Orthop Sports Ther. 2006; 36(8):550-556. doi:10.2519/jospt.2006.2136
Weight-Bearing Passive Dorsiflexion of the Hallux in Standing Is Not Related to Hallux Dorsiflexion During Walking
J. Halstead, A.C. Redmond
Study Design: Case control study.
Objective: To explore the validity of the assumptions underpinning the Hubscher maneuver of hallux dorsiflexion in relaxed standing, by comparing the relationship between static and dynamic first metatarsophalangeal (MTP) joint motions in groups differentiated by normal and abnormal clinical test findings.
Background: Limitation of motion at the first MTP joint during gait may be due to either structural or functional factors. Functional hallux limitus (FHL) has been proposed as a term to describe the situation in which the first MTP joint shows no limitation when non-weight bearing, but shows limited dorsiflexion during gait. One clinical test of first MTP joint limitation during standing (the Hubscher maneuver or Jack’s test) has become widely used in physical therapy, orthopedic, and podiatric assessments, supposedly to assess for the presence of hallux limitations during gait. The utility of the test is based on an assumption that restriction during the static maneuver is predictive of functional limitation at this joint during gait. Despite a lack of evidence for the validity of such an assumption, the outcome of the static test is often used to infer risk of overuse injury or as an outcome for functional therapy. This paper examines the validity of the assumptions supporting this widely used static test.
Methods and Measures: First-MTP-joint motion was assessed using an electromagnetic motion tracking system in cases (n = 15) demonstrating clinically limited passive hallux dorsiflexion in relaxed standing, and in 15 controls matched for age and gender and demonstrating a clinically normal Hubscher maneuver. Maximum hallux dorsiflexion was measured with the subject non-weight bearing (seated), during relaxed standing, and during normal walking.
Results: Hallux dorsiflexion was similar in cases and controls when motions were measured non-weight bearing (cases mean ± SD, 55.0° ± 11.0°; controls mean ± SD, 55.0° ± 10.7°), confirming the absence of structural joint change. In relaxed standing, maximum dorsiflexion was 50% less in cases (mean ± SD, 19.0° ± 8.9°) than in the controls (mean ± SD, 39.4° ± 6.1°; P<.001), supporting the initial test outcome and confirming the visual test observation of static functional limitation in the case group. During gait, however, cases (mean ± SD, 36.4° ± 9.1°), and controls (mean ± SD, 36.9° ± 7.9°) demonstrated comparable maximum dorsiflexion (P = .902). There was no significant relationship between static and dynamic first MTP joint motions (r = 0.186, P = .325).
Conclusion: The clinical test of limited passive hallux dorsiflexion in stance is a valid test only of hallux dorsiflexion available during relaxed standing. There is no association between maximum dorsiflexion observed during a static weight-bearing examination and that occurring at the same joint during walking. J Orthop Sports Ther. 2006; 36(8):550-556. doi:10.2519/jospt.2006.2136
Nice work.
Makes sense mechanically when we use physics to model this. Y'all who don't believe that physics can be applied to biological systems may find this a bit more difficult to fathom though.
On the down side, the study tells us nothing about timing of dorsiflexion or kinetics required to achieve the dorsiflexion between the two groups.
Sagittal plane theorists would argue the the timing is key, tissue stressors, that kinetics is key.
Makes sense mechanically when we use physics to model this. Y'all who don't believe that physics can be applied to biological systems may find this a bit more difficult to fathom though.
You all, don't you know that the correct word is not "physics" but is "fizzicks" and can only be applied to dead people or Coca Cola?!! I mean, you should understand that when a live person weighing 70 kg is dropped from an airplane and their parachute fails to deploy and then hits the hard, unyielding flat surface traveling 36.0 m/sec that you cannot use "fizzicks" to calculate their kinetic energy at the moment of impact. However, if the person was first shot, killed and then thrown out of the plane and hit the ground traveling 36.0 m/sec that you could then use "fizzicks" to calculate their kinetic energy at the moment of impact with the ground!!
"Fizzicks" can only be used on dead things!! Everyone that learns their scientific knowledge and definitions from the internet knows that about "fizzicks"!! You all need to learn the real definition of "fizzicks" so that you can better understand the negative interactions of the dead human body with hard-flat surfaces. :p
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Let's see, Simon's article showed a significant decrease in 1st MTP DF with varus and valgus wedges. Michaud and Nawoczenski showed the same thing in one patient (Simon what is the beta error on that?) Then in the conslusions of both papers it is stated that the decreased DF is a good thing? Except for trauma, I haven't seen too many Hallux Limitus patients complain of not enouth PF. It is usually DF limitation that is a problem.
What I get out of both of these papers is, if you want to increase 1st MTP DF grind off the post or wedge.
Let's see, Simon's article showed a significant decrease in 1st MTP DF with varus and valgus wedges. Michaud and Nawoczenski showed the same thing in one patient (Simon what is the beta error on that?) Then in the conslusions of both papers it is stated that the decreased DF is a good thing? Except for trauma, I haven't seen too many Hallux Limitus patients complain of not enouth PF. It is usually DF limitation that is a problem.
Ed
Ed, it's not a good idea to say that an author concluded something, when he so didn't and also has the opportunity to show the rest of the readership of Podiatry Arena that he so didn't. This kind of spin may work on your website, but not here.
So here is the "conslusion" or conclusion as we called it from our paper in full:
"Conclusion
This study sought to provide further information about foot function and the management of foot pathology by evaluating the effects of 5 degree valgus and varus rearfoot wedging on peak hallux dorsiflexion at the first metatarsophalangeal joint. Within the limitations of the study, the results suggest that both forms of wedging had a statistically significant effect on peak first metatarsophalangeal joint dorsiflexion, with reductions occurring with both types of wedging. Furthermore a statistically significant difference was found when the effects of valgus and varus wedging were compared, with first metatarsophalangeal joint dorsiflexion more significantly reduced with varus wedging in place. These results may have implications for the clinical management of disorders of the first metatarsophalangeal joint, such as hallux limitus."
So exactly where within this do we state that "the decreased DF is a good thing?"?
Quote:
Originally Posted by EdGlaser
What I get out of both of these papers is, if you want to increase 1st MTP DF grind off the post or wedge.
This statement reveals a complete lack of understanding of our study (I can't make comment for the other authors). The word 'increase" here is great and demonstrates the mind of a genius/ salesman (you decide) at work.
First MPJ ROM and foot orthoses
:p
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