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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.
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.
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.
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.
Quote:
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.
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...
LL
__________________
***************************************** Remember, it's just a foot.
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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.
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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.
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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.
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.
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.
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!
...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!
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
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?
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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.
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
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?
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.
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
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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
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
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.
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
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.
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
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!
too much pressure sub 1 will not require more force to dorsiflex the hallux.
Quote from www.breakthroughpodiatry.com
Can orthotics address the faulty biomechanics of metatarsalgia
Guest: Bruce Williams
"If clinicians load the first metatarsal head and attempt to dorsiflex the hallux,they will usually see a limitation of motion in patients with functional hallux limitus".
too much pressure sub 1 will not require more force to dorsiflex the hallux.
Quote from www.breakthroughpodiatry.com
Can orthotics address the faulty biomechanics of metatarsalgia
Guest: Bruce Williams
"If clinicians load the first metatarsal head and attempt to dorsiflex the hallux,they will usually see a limitation of motion in patients with functional hallux limitus".
Is this not the same thing Bruce?
Scott
Scott;
I appreciate that you have visited my website and I hope you found it informative.
I would appreciate it as well if you re-read my last post that suggested you are confusing a non-weight bearing evaluation of the foot with actual weight bearing function during gait. The two are not the same though not mutually exclusive either.
the test from the quote you noted above is non-weight bearing and primarily elongates the medial colum as the metatarsal is dorsiflexed. As I stated before the majority of the force is whithin the 1st mpj and this is what make it more difficult to DF the hallux non-weightbearing.
in the Weight bearing condition much of this is true wiht added features such as the opposite limb heel striking prior to DFion at the FnHL site of the mpj and decreased hip extension on the FnHL limb and early knee flexion prior to DFion of teh mpj after full weight bearing as been transfered to the contralateral limb.
You are missing the point here by a long shot via over simplification. you can get teh same non-weight bearing result in the FnHL test by pressing up under the planter fascia of the medial band in most patients all the way to the base of the 1st metatarsal. yes it limits DFion of the hallux and would require more force to DF the hallux. But, this isn't even an issue in gait until the weight is on the other limb in the majority of FnHL patients. Think this thru and I think you will see what I am saying.
too much pressure sub 1 will not require more force to dorsiflex the hallux.
Quote from www.breakthroughpodiatry.com
Can orthotics address the faulty biomechanics of metatarsalgia
Guest: Bruce Williams
"If clinicians load the first metatarsal head and attempt to dorsiflex the hallux,they will usually see a limitation of motion in patients with functional hallux limitus".
Is this not the same thing Bruce?
Scott
Scott:
Let me see if I can help.
One thing that you must be careful of when discussing functional hallux limitus (FnHL) is cause and effect. The cause of FnHL is a reduced dorsiflexion stiffness in the first ray structures that are proximal to the 1st metatarsophalangeal joint (MPJ). When the subtalar joint (STJ) pronates in stance, the increased elongation of the medial arch will cause over-flattening of the medial longitudinal arch due to this reduced first ray dorsiflexion stiffness which will, in turn, cause a large increase in passive tensile force within the plantar fascial strands that attach to the sesamoids and base of the proximal phalanx of the hallux.
The increased plantar fascia tensile force will cause an increased 1st MPJ plantarflexion moment which will cause the hallux now to more forcefully plantarflex toward the ground causing increased ground reaction force (GRF) sub-hallux. The plantar first metatarsal head then will have reduced GRF in FnHL due to the increased compliance in the first ray structures that are proximal to the 1st MPJ that, effectively, allows the first metatarsal head to be dorsiflexed excessively relative to the hallux when the STJ pronates.
It is this increased 1st MPJ plantarflexion moment from the increased plantar fascial tensile force that helps cause FnHL since it is this 1st MPJ plantarflexion moment that resists the 1st MPJ dorsiflexion moment from GRF on the plantar hallux sufficiently to prevent normal hallux dorsiflexion during propulsion.
Therefore, STJ pronation causes:
1. medial shift in GRF on the plantar forefoot
2. increase in medial longitudinal arch flattening
3. increase in plantar fascial tensile force
4. increase in 1st MPJ plantarflexion moment
5. increase in plantarhallux GRF
5. reduction of normal hallux dorsiflexion during propulsion
Hope this helps.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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
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.
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.
Excuse the dumb question, but could someone tell me what a shaft pad is?
Hallux Limitus/Rigidus
Linear Mode
