Podiatry Arena members do not see these ads

Hi,

I have an elderly lady (78) developing a painful hyperkeratotic lesion to the plantar aspect of her left hallux IPJ. Well controlled NIDDM 12 years. Joint contributing to classic trigger toe morpholopgy, with prominence of the plantar joint aspect - subsequent dermal erosion is developiong. The MPJ shows notable hallux limitus - joint ROM decreases under functional loading. Generalised midfoot stiffness and moderate collapse of the 1st met-navicular joint during midstance. Any ideas regarding suitable offloading techniques? Feedback would be most appreciated. Thanks in advance.

Chris Williams

Chris

This common situation can be approached a variety of ways. Obviously the goal is to prevent any form of breakdown under the hallux IP joint.

Terminology is important here. A 'trigger toe' deformity, common in the neuropathic foot, will cause a flexion deformity of the hallux at the IP joint. By contrast, the classic compensation for hallux limitus an MT primus elevatus, is a "hallux extensus" deformity - whereby there is hyperextension of the IP joint to compensate for reduce extension of the 1st MTP joint. I suspect your patient has the latter.

My approach for these patients is to note that as hallux limitus worsens, the IP joint becomes the primary point of contact for the medial column in the forefoot. Contracture of the 1st MTP joint, and proximal migration of the sesamoids, along with MT primus elevatus (which comes first?) - leads to a "hallux equinus" and lack of weight bearing under the 1st MT head.

Solution? Aside from correcting for more proximal frontal and sagittal plane factors in your orthosis - provide the patient with an extrinsic forefoot varus posting, to bring the ground up to the 1st MT head, and taper down to the IP joint. That then gets the 1st MT head contributing to forefoot contact and reduces plantar pressure under the hallux IP joint.

Remember to check for a cartilagenous accessory hallux IP joint ossicle.

Can be used +/- rocker sole modification also.

Hope this helps,

LL

__________________
*****************************************
Remember, it's just a foot.

Be careful with the varus posting. it can drifit the forefoot weight laterally resulting in an increased abductory twist at propulsion creating more stress on the IPJ of the Hallux.

If you can not improve first ray function with a first ray cut away, I will add a morton's ext with a cavity under the ipj with gel/plastazote - if this alone is not adequate you may have to add a rocker sole to the shoe with the apex just a smidge distal to the met heads.

regards

__________________
Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Hi,

I agree in different ways to both approaches here.

A forefoot varus extension to sulcus wedge will increase the load on the 1st mpj and hopefully reduce the pressure on the 1st I.P.J, however it will reduce hallux dorsiflexion/1st met plantarflexion.

If the hallux is only limited on weightbearing (FHL) you might want to try what graeme suggested by attempting to promote 1st MPJ R.O.M by reducing GRF plantar to the 1st M.P.J with use of a 1st met/ray cut out and a reverse mortons extension to increase GRF lateral of the 1st mpj,

If there is sufficient depth in the toe box of the shoe, a full length extension of medium density 3mm eva/cork/poron with a cavity to accomodate for the trigger toe and a 3mm p-cell/plastazote top cover to reduce peak load furthur.

I used this combination of top cover/extension/cavity 2 months ago in an elderly gentleman with a trigger toe. He reported that his 1st I.P.J pain was significantly reduced.

Regards


Footdoctor

I can offer the following. First, consider an ankle manipulation. This can restore ROM of the ankle which results in decrease forefoot stress and an increase in peroneal strength. By facilitating the peroneus longus, 1st met plantarflexion improves and the jamming of the 1st MTP joint reduces. Second, consider an adjustment of the 1st met-cuneiform joint. This can effectively increase 1st MTP joint ROM thus relieving pressure of the sub hallux site. Hope that this helps.

Information on manipulation available at www.vasylimedical.com.

Howard

Related:
How do you resolve chronic wounds at plantar/medial hallux?

__________________
Are you addicted to Podiatry Arena?
Have you added your location to the map? (Map FAQ's)
Earn CPD Points

I usually go with the rocker bottom idea. First I make a narrow plantar felt pad which extends from the base of the first metatarsal to the IPJ. Taper both ends from a pivot point plantar to the 1st MTPJ. Adhere this to the underneath of the shoe insole, or directly to the foot. If that is successful, I usually make a non cast insole with an EVA addition similar to the felt pad. I find this works well as rocker bottom shoes can be very difficult to adjust to, especially in an elderly patient such as yours.
Beth.

This can be a difficult one especially if there is hallux limitus/rigidus present. there is naturally a increased forces on the IPJ.
I have had best outcomes with andf orthotic with a full length soft tissue extension and full lenght soft tissue extention of PPT and hollow uot under the 1st IPJ. I have been trying silicone gel plug under the IPJ and incorporated into the top cover.
Chris

Beth

What type of EVA insole modification?

Lawrence

With an elderly lady of 78 , I would have a look at her current footwear and see if she is prepared to change. A stiffer sole would reduce pressure to the IPJ, or if possible and room permits adding a shank to the sole.

I have found the reverse Mortons extension helpful and have not had great success with orthotics for this condition.

Flat innersoles with a cut out have also helped.

hi,
i'm starting a study on the first ray...
Do u think, or do you know an another test, who prove the relation between an inactif first ray (to pré-form) an a later pronation of stj?
thanks you
friendly
Genthon Mathieu

I agree with a true forefoot post. Poron varus extension to the sulcus one quarter inch medialy skived to nothing by 4rth or 5th metahead . Do a quick skive distaly at the sulcus. This also helps with excessive pronnators,tibia varum,HAV etc.

Hi Lawrence,
Sorry for the long delay, I've been away for the Australia day long weekend.
I make an EVA pad from a soft EVA (beige or light blue) in the same shape as the felt pad that I described and fit it to an insole (cork insole works).
Beth.