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Hello all!

I am hoping someone will clarify a few daft questions for me. The first is regarding the treatment of hallux limitus. I always read about kinetic wegdes and from the few pictures I have found, the kinetic wedge appears to be an insole up to the toe sulci with a 1st met cut out-is this correct?

The second is the appropriate use of medial heel skives. I understand that these are used in order to control excessive pronation of the foot by supinating the foot? Would a skive be used in addition to rearfoot posing to gain extra control?

Once again appologies for these questions which I am sure I should know as a graduate, however my uni was not that hot on BMX assessments!

Thanks

Victoria

The 'Kinetic Wedge' is a patented design that is basicaly just that. It is one of several methods available to facilitate first MPJ function when functional (as opposed to structural) hallux limitus or one of the windlass dysfunctions are present. Rearfoot posts are allegedly used to change the angle of the rearfoot (though they don't actually do this). Medial (aka Kirby) skives are indicated when more force is needed to achieve the alleged change in rearfoot angle (ie supination resistance is higher).

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
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Kirby's original description of the medial skive:
KA Kirby: The medial heel skive technique. Improving pronation control in foot orthoses. J Am Podiatr Med Assoc 1992 82: 177-188

Dananberg's original description of the Kinetic Wedge:
HJ Dananberg: Gait style as an etiology to chronic postural pain. Part I. Functional hallux limitus. J Am Podiatr Med Assoc 1993 83: 433-441.

Danaberg's patent here.

Related threads:
Fnl Hallux Limitus-?etiology
Foot orthoses for functional hallux limitus
Functional hallux limitus and longitudinal arch flattening
Functional hallux limitus
Forefoot supinatus with painful hallux limitus
Where Should the First Ray be When Casting for Orthoses?
Foot pronation and 1st MPJ motion
The long and short of hallux limitus

Pros and Cons of DC wedge orthoses
Skives and posts
Do Rearfoot posts Work?

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As always, Podiatry arena is shown to be a great source of knowledge and guidance.
Admin2 has kindly posted links to a couple of very important articles, however, how does one get a copy of these without access to a university library??
JAPMA online only has electronic copies from about 1999-
I would like to read Howard Dananberg's 2 papers (I have the 2 books of Precision Intricast Newletters, so I think I have Kevin covered!)... any suggestions how I can do this without having library access?
Thanks in advance.

__________________
Craig Tanner
Podiatrist
ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR
http://www.aspetar.com/

CraigT

I There are many ways of finding the papers you need ie Pub Med, Elsiever, science direct, wiley interscience, Data trace and loads more but Google or Google scholar is a good place to start.
Once you've found the paper and read the abstract, which is usually free, you can go to the appropriate site and down load the paper for a small fee of between $12 and $30. More often than not its the lower price. Unfortunately if you don't have Athens or an institutional access most new papers are not free. Many older papers are available free somewhere if you search hard enough. Sometimes there are back doors into sites that are usually pay per view. (don't ask me how, but if you surf enough they are there) If you want regular access to quality papers in the podiatry field then subscribe to Japma (maybe you already do) and I would recommend Foot and ankle Int thru Data trace which is quite inexpensive. Also Dannenburgh in association with Vasyli is publishing articles in Podiatry Now and probably other publications to promote the new Vasyli/Dannenburgh OTC product. It claims to improve saggital plane proggression and these articles describe the principles of saggital plane theory in terms of improved Hallux dorsiflexion that is facillitated by the orthoses.

All the best Dave Smith

Thanks David,
I understand about the subscriptions and pay per view, however the problem is that JAPMA states that it does not have electronic copies available online- abstract only.
I have a friend who can access online articles through institutional access, however the articles I mention do not appear to be available. It would seem that I would have to find an insitution withe a hard copy- not easy to do in Qatar!!

__________________
Craig Tanner
Podiatrist
ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR
http://www.aspetar.com/

CraigT

Hello again, This article is available thru JAPMA at $12 or free if you have subscription
Journal of the American Podiatric Medical Association, Vol 90, Issue 1 47-50, Copyright © 2000 by American Podiatric Medical Association


JOURNAL ARTICLE
Sagittal plane biomechanics. American Diabetes Association

HJ Dananberg
American College of Foot and Ankle Orthopedics and Medicine, Bedford, NH 03110, USA.

------------------------------------------------------------------------------
And this one

Journal of the American Podiatric Medical Association, Vol 89, Issue 3 109-117, Copyright © 1999 by American Podiatric Medical Association


JOURNAL ARTICLE

Chronic low-back pain and its response to custom-made foot orthoses
HJ Dananberg and M Guiliano
American College of Foot and Ankle Orthopedics and Medicine, Bedford, NH 03110, USA.

And this is a good site http://www.latrobe.edu.au/podiatry/sagittal.html the theory is all dananberg and payne (and Free)

La Trobe University Department of Podiatry

Sagittal Plane Facilitation of the Foot

And here's a good article in Physical Therapy at http://www.ptjournal.org/cgi/content/full/79/9/854 (free download)

PHYS THER
Vol. 79, No. 9, September 1999, pp. 854-859

Anatomy and Biomechanics of the First Ray
Ward M Glasoe, H John Yack and Charles L Saltzman



Cheers Dave

Victoria and Craig:

I can send you a pdf copy of my medial heel skive paper if you send me your e-mail address privately. 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

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

David- Thank you once again for the references- the La Trobe link is certainly a very useful resource.
I actually have most of those already as I do have access to JAPMA online via an institution. I also have a pretty good handle on sagittal plane theory.
The problem I have is accessing articles such as these ones below...

Dananberg HJ: Gait Style as an Etiology to Chronic Postural Pain. Part 1.Functional Hallux Limitus. Journal of the American Podiatric Medicial Association 83(8)433-441 1993
Dananberg HJ: Gait Style as an Etiology to Chronic Postural Pain. Part 2.Postural Compensatory Process Journal of the American Podiatric Medicial Association 83(11)615-624 1993

Call me old fashioned, but I like to read original articles and these are very widely referenced. JAPMA only has them online from 1996- before this they have abstracts only. If I had a personal JAPMA subscription would they suddenly be available???

Kevin- Thank you for your offer- I have emailed you directly!

__________________
Craig Tanner
Podiatrist
ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR
http://www.aspetar.com/

CraigT

Yeah I see your problem, I have searched all Scottish and English libraries and specifically some Universities that specialise in biomechanics both clinical and bioengineering but none available in full electronic or hard copy only electronic abstract which are available from JAPMA only.

Reply from Strathcyde UniversityLibrary Help Desk
E-mail Address(es): libraryhelpdesk@staffs.ac.uk


We do stock the Journal of the American Podiatric Medical Association in the Thompson library but only from 2003 onwards. To obtain the articles you are looking for I suggest using our document delivery service who will be happy to order your articles at a cost of £5 per article. The document delivery office in the Thompson library is open from 9 till 5 every weekday.

Cheers Dave Smith

CraigT

Is this helpful?

Dear Dr. Smith,

If you are a member of APMA, we can send you hard copies of those
articles at no charge (full-text articles are online only for material
published in 1996 and later). If you are not an APMA member, there is a
charge of $12.00 per article. I am copying Susan Austin of the APMA
Membership Department (phone: 1-800-ASK-APMA, ext. 271) on this reply.
She is in charge of handling orders for single articles.

Thank you for your interest.

Cheers Dave

That's very helpful!
Thank you for your efforts in answering my questions- very much appreciated.
Cheers
Craig

__________________
Craig Tanner
Podiatrist
ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR
http://www.aspetar.com/

I just noticed this:
Always the alleged cynic. That word "alleged" should appear in a lot more podiatric biomechanics texts :)

Craig T:

Did you get my articles??

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Hi Kevin-
Yes I did thank you! I am just in the process of writing you a reply... :)
As I said in my first post on this topic- it is great to a resource such as this!
Thank you all!

__________________
Craig Tanner
Podiatrist
ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR
http://www.aspetar.com/

Hi all,

with regards to functional HL and associated joint pain:

I have a male (middle aged) pt who has normal ROM at the 1st MTPJ; Hoewver, this is is a FHL on weightbearing due to a PF 1st ray.
On dorsiflexion (both open and closed chain) he had pain in this joint. As such he has insufficent push off during gait and early heel lift due to this problem and through pain avoidance.
I am cautious about adding a heel lift (as he has gastroc equinus) and 1st met cut-out due to the pain. Surley thses additions will worsten the pain? How can I encourage normal push off and reduce the pain?

Regards

Rob

Rob,

You noted that this patient has a PF 1st met....don't you mean DF (dorsiflexed) 1st. Fhl is generally not present when the 1st ray is plantarflexed. If you have a long 1st c/o on a plantarflexed met....it no wonder there is pain.

Clarify the exam findings and I can offer some insight into care.

Howard

Hi Howard,

it is PF on non-weight-bearing exam and is then consequently max. Dorsiflexed during gait - leading to jamming.

I hope that makes sense

Rob

Rob

I would suggest that, if you want to facillitate sagittal plane progression but at the same time restrict or allow minimum hallux dorsiflexion, use a stiff rocker sole shoe. This will also reduce the need for heel lifts.

Why is there pain non w/b? is it that the FncHL causes compression trauma of the 1st MPJ and so it is painful non w/b as well as in gait. If so, it is possible that when the FncHL is addressed with appropriate orthoses then the non w/b pain thru the dorsiflexion RoM will resolve over time. You could try a combination of Rocker shoe and orthoses to address both problems at once, plus some therapy for the local trauma eg ice, taping, ultra sound etc and see if the non w/b pain has resolved at review.

Cheers Dave Smith

Hi Dave,

thanks for this.
I am keen to maintain 1st MTPJ motion, especially since its a FncHL at this stage. What are you thoughts on 1st MTPJ manipulation with anesthetic/steroids - followed by orthoses?

Regards

Rob Cox

Guys,

If you check peroneal strengh, you will find it weak. This actually sounds like an arthrogenic inhibition caused by (I think) a restriction to fibula translation. Since muscles protect the joints about which they function, failure to facilitate normal peroneal strength causes the 1st MTP joint to be "unprotected". Symptoms result. The treatment involves manipulation of the ankle. This can provide instant relief. It is most remarkale.


Howard

Hi Howard

by "unprotected" do you mean that there is a loss of first ray stabilisation - leading to jamming at the 1st MTPJ?

Regards,

Rob

Rob

I'm no expert in mobs and manips and the best people to take advice from are the Dr's Danaberg and Beekman. As far as ankle mobs are concerened I use the technique as described by Dr Dananberg (Dananberg HJ, Shearstone J, Guiliano M (2000) Manipulation method for the treatment of ankle equinus. Journal of the American Podiatric Medical Association) and modified in the way that I have learned from my many communications with Dr Stanley Beekman.
I find I get remarkable results from this practice , which has become almost routine when I find ankle equinus. I define equinus in the ankle when the ankle cannot reach 10dgs of d/flex with assisted active dorsiflexion. I regularly get an increase of 10dgs + d/flex.
Try this link
http://www.latrobe.edu.au/podiatry/m...phxtheory.html

As far as mobilising the 1st MPJ I would think in your case that a period immobilisation would be better eg by fan taping and / or rocker shoe. Then orthoses, as described before

I have no experience with manipulation and injections of anesthetic/steroids.

Here are some other articles of interest:

JAPMA Letter to Editor by Hylton Mendez reviewing the Dananberg paper and his reply.

Journal of the American Podiatric Medical Association Volume 91 Number 2 105-106 2001

http://health.groups.yahoo.com/group...-manipulation/

Cheers Dave

Dave

thanks for this information. I will take a further look at the papers you have mentioned.

Regards,

Rob

Hi Rob
Just as a simple first step- have you tried low-dye taping??
I understand your reluctance to do the orthotic additions you state as in theory you create more movement in the joint(am I correct that this is that your concern?). However, you must also consider that it is not necessarily the movement which is the problem, but the force on the joint. Although you may facilitate more sagittal plane movement, at the same time you will decrease the jamming force on the joint. This may give the result you are after, and the taping usually gives a good idea how effective this strategy would be.
Cheers,

__________________
Craig Tanner
Podiatrist
ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR
http://www.aspetar.com/

Hi Craig,

thanks for this feedback. Low-dye-taping is something I haven't used before. It is something I will look into. Can you suggest any good literature on this?

Regards


Rob

Rob,

If you want to tape the foot, then use a plantar figure 8 taping, or just add the medial side of a figure 8 to the Low- Dye taping.
The first met cuneiform joint allows the first metatarsal to plantar flex and adduct. The Low- Dye taping plantar flexes and abducts the first metatarsal, while the figure 8 taping plantar flexes and adducts the first metatarsal.
As far as the literature, if you can find a Monograph by Ralph Dye, then that would give you the original writing of Ralph Dye on his taping.
My take on FnHL, is similar to Howard’s in that the cause is the inhibition of the peroneus longus. Just to add to this, there are other causes of inhibition of the peroneus longus. Classically, a limbic fixation can cause this.
Additionally, I would like to add my observations about the pathomechanics of the first MPJ with FnHL. As the first metatarsal dorsiflexes and the joint ROM decreases, there is additional stress placed on the plantar ligaments and fascia at propulsion. The soft tissue tightens and causes an additional decrease in the first MPJ ROM. A simple myofascial release consisting of distal friction to the area of the tibial sesmoidal and fibular sesmoidal ligaments appears to be a helpful adjunctive treatment.

Regards,

Stanley

Hi Stanley

thanks for this info. How long would you leave the taping on for?

regards

Rob

Hi Rob,

Taping lasts 3-4 days. I have the patient leave the taping on until their next visit. They see me twice a week for therapy and taping until the orthoses (with a metatarsal head cut out under the metatarsal head) come back from the lab.
By the way, on my first visit I take radiographs in the AP, lateral, and stress lateral (lateral view with the patient mimicking the end of propulsion), so I can see if there is a boney block or if there is just a soft tissue restriction. If it is just soft tissue, you will be pleasantly surprised. If it is boney, the prognosis is not as good,


Regards,

Stanley