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I am treating a patient at the moment who has a hyperextended IPJ of the hallux. Therefore the distal condyles of the proximal phalanx is receiving excess ground reaction forces, resulting in callus build up on the plantar surface of the IPJ, and at last appointment a breakdown underlying the callus was present. I have attempted to off load the area by placing some felt in her shoe just proximal to the high pressure area. This is in an attempt to DF the MPJ by applying pressure to the proximal phalanx, therefore off loading the plantar IPJ. It's good in theory but I'm not confident this will work and am concerned that she may present with an ulcer next visit. Has anyone got some suggestions on how I should go about off laoding the area??

I would try the opposite - try a felt pad over the lesion to dorsiflex the hallux --> the first met (via the windlass) will take more of the weight. Those that have tried this have, anecdotally, been surprisingly pleased with the outcomes.

Dorsiflexing the MPJ with padding under it, may hyperextend the IP joint even more, increasing pressure during propulsion.

CP

If in-shoe offloading is unsuccessful, you could try a rocker bottom sole with the apex at the level of the metatarsal head area. You may also need a rigid shank.

Hyperextension of the IP joint of the hallux is almost sure-fired to suggest hallux limitus, in whatever form.

A couple of hints for young players, after seeing billions of these;

1. Check for accessory ossicle plantar to the IP joint. This may be somewhat cartilagenous, and may require x-ray with good soft tissue contast.
2. Deal with any hindfoot valgus compenent correctly with a functional foot orthosis. If they are a 'pronator', make sure this is adequately addressed.
3. A simple accomodative felt pad over the lesion will definitely help healing, but may not be the answer in the long term.
4. For recurrent ulcerations at this location a Kellers arthroplasty is an ideal day surgery procedure, and has been demonstrated by Armstrong et al to be very effective - talk to you local podiatric surgeon.

hope this helps,

LL

I am not a wound expert, but agree that everything must be done to reduce the contract pressure. Your idea makes sense. Others would add that plantar flexing the 1st ray may also promote "easier" MPJ dorsi-flexion. This inturn must reduce the GRFs absorbed by the IPJ.

Others may suggest a period in a surgical boot or mini-cam?

Rockersoles reduce the amount of MPJ motion during gait. Would this have a bearing on the contact forces more distallly???

Depends on other factors I guess.

Try an orthotic device with a morton's extension to relieve pressure in that area.

TEW, how did you get on with this patient?

Quote:I am treating a patient at the moment who has a hyperextended IPJ of the hallux. Therefore the distal condyles of the proximal phalanx is receiving excess ground reaction forces, resulting in callus build up on the plantar surface of the IPJ, and at last appointment a breakdown underlying the callus was present. I have attempted to off load the area by placing some felt in her shoe just proximal to the high pressure area. This is in an attempt to DF the MPJ by applying pressure to the proximal phalanx, therefore off loading the plantar IPJ. It's good in theory but I'm not confident this will work and am concerned that she may present with an ulcer next visit. Has anyone got some suggestions on how I should go about off laoding the area??

From the suggestions you received from CP and others, I can see that a padding over the lesion or the length of the hallux would reduce pressure at the plantar IPJ by improving the windlass mechanism, but it would increase pressure to the dorsal distal phalanx and distal nail from shoes, because the IPJ is hyperextended.

I am interested in your initial treatment of padding under the shaft of the proximal phalanx. I'm definitely no expert but it seems to make sense to me. This way you:
offload the plantar IPJ
promote the windlass mechanism
reduce irritation to the nail in shoes
negate the need for rocker-soled footwear

I hope to hear from someone who uses the above with success and / or from someone as to why it might not work, to put my mind at rest.

Rebecca

You might try placing 5mm s/c white felt as a met bar 2-5...does in-shoe what a Thomas's bar does on-sole. G/f is taken off medial column...immediate relief. Protect hallux IPJ with one layer brushed cotton fleecy web.

Dorsiflexing the hallux (already hyperextended) must bring nail against toebox of shoe. Plantarflexing the hallux allows more ginglioarthrodial movement at the 1st MPJ - the hallux is still heavily loaded.

No, Johnpod, the hallux is not hyperextended, the interphalangeal joint is hyperextended.

A prop under the shaft of the proximal phalanx would dorsiflex the proximal phalanx at the 1st MPJ (good thing - windlass mechanism) and allow plantarflexion of the distal phalanx (good also - less irritation of the distal dorsal phalanx / nail).

Yes / No?

No, Asher -with respect I cannot agree.

Placing a raise beneath the proximal phalanx must dorsiflex the hallux. The distal phalanx must go with it and, if the IPJ is hyperextended, must bring the nail against the toe-box. Try it on yourself to appreciate this.

It has been suggested that movement at the 1st MPJ is already limited. Raising (dorsiflexing) the proximal phalanx is going to use part of the still available movement at the MPJ. To extend the movement available at the MPJ it is necessary to allow the 1st ray to plantarflex. If the first ray can plantarflex there will be greater ginglimoarthrodial movement available at the 1st MPJ. The method suggested works in exactly the same way as a 1st ray cut out in an orthotic shell. The 1st met can then plantarflex and move backward - this will improve the windlass mechanism.

This may all be irrelevant if the concern is simply to protect the vulnerable IPJ. A simple directly adherent pressure-relief dressing can easily be applied for this purpose.

Placing a raise beneath the proximal phalanx will dorsiflex the proximal phalanx on the 1st met head (not necessarily the entire hallux). My thought is that the distal phalanx will not go with it if the IPJ hyperextension is not fixed and therefore the nail is not lifted into the toebox. That's the thing, I have done it on myself and a few others (with a hyperextended IPJ) and this is what happens.

Johnpod, I'm not sure that it has been suggested that movement at the 1st MPJ is already limited, not in a structural sense, my interpretation is that this is a functional hallux limitus.

ginglimoarthrodial movement - far out, I don't even know what this means (embarrassed).

You mention: This may all be irrelevant if the concern is simply to protect the vulnerable IPJ. A simple directly adherent pressure-relief dressing can easily be applied for this purpose.

Yes but if you extrapolate this to an ongoing pressure lesion (ulcer / HD / callus / just a sore spot on your morning walk) what can we do which will best offload the plantar aspect of a hyperextended IPJ without causing irritation to the nail but still promote windlass function?

Respectfully

Rebecca

Dear TEW,

In the past i have had quite reasonable success in the acute wound stage with Ottoform to create the desired off-loading and biomechanical effects which have been described previously. Just an extra thing to try if you find that the felt isnt working to well.

I created the ottoform type splint in semi-weightbearing.

REgards


Ryan

I am currently treating a patient with similar problems. This is what has worked (patient has a functional hallux limitus):

Correct all pathomechanics with orthotics and include a REVERSE Morton's extension with 1st ray cut-out to assist with dorsiflexion.

The patient's ulcer healed completely within 3 weeks of using the device.