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Much has be written on tx for hallux limitus (kinetic wedge,fascilitate first ray arthrokinematics, etc), but what about painful stage 2 or 3, where there is little motion and the joint is degenerated?

Aside from shoe modification (which most patients are not happy about), orthotically I typically add a rigid morton's extension with mixed results. Is there anything else that helps with regards to the orthotic Rx ????

Nick

I haven't dealt with this type of patient as much as some on here, although I have just had surgery on both 1st MPJ's for something similar. I too have added a morton's extension to an orthotic and a shank with mixed clinical results.

The older the patient, the more we should perhaps try to just get them over-the-line functionally with minimal symptoms. Would a stiff soled shoe or a carbon fibre shank addition achieve anything? What about a rocker bottom/sole? I think that the anachronistic forefoot varus post could actually function as a localised rocker for the 1st MPJ. Yes, I know that the 1st ray would dorsiflex, and windlass dysfunction would ensue; but in the elderly with painful HR, to hell with optimal biomechanics as we know it.

Ron

Hi,

Presuming the patient absolutely cannot have Sx (as joint replacements can be great with good post-op Physio), I've had good success with (and I am ashamed to say this) MBTs!!!!!!

The success rate with these have been much higher than adding a Rocker sole to an existing shoe, due to compliance (goodness knows why patients are more likely to want to wear MBTs than Rocker soles, but they defnitely do)!

I've also had only mixed results with orthoses additions, but stiff-soled shoes usually help quite a bit (patients have usually figured this out on their own though!)

__________________
nicpod1

I will try inverting the orthosis and using a medial heel skive with minimal arch fill to try and supinate the foot so that the GRF is reduced plantar to the first metatarsal head. Over-supination of the foot by the orthosis, however, may cause increased late midstance pronation which will exacerbate the symptoms. Use at least a 3 mm thick Morton's extension on the orthosis.

If this does not work, using rocker bottom or clog style shoes with the orthosis may help. I have even used thin steel plating underneath the orthosis extending across the 1st MPJ area from proximal to distal to help prevent the shoe from bending during propulsion at the 1st MPJ area.

If these conservative treatments do not work, I schedule the patient for surgery which generally gives a very predictable good to excellent result.

__________________
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
**************************************************

G'day Nick,

There are many shoes available today including Athtletic shoes, that have rigid soles and have an excellent toe spring (or rocker soles). That is why the MBT's work. My expericence is that foot orthoses especially with a Morton's extension are more of a hindrance in managing Hallux limitus or rigidus. Sorry guys

When it comes to choice of surgery or shoe modifcation, I know what I would choose

Good luck mate.

Mr/Ms. Caf002:

The patients that I have been treating for over the past two decades with painful hallux limitus and hallux rigidus who have been walking with less pain with each step with Morton's extensions on their orthoses certainly don't find decreased pain and increased walking endurance to be "a hindrance". I routinely perform hallux rigidus/limitus surgeries quite successfully, but that is not the point. I wouldn't call a foot orthosis with a Morton's extension that allows a patient that wants to avoid surgery to walk painfree "a hindrance". It just may be that the podiatric surgeon (or orthopedic surgeon, for that matter) that feels that any treatment that is less than a surgery is "a temporary treatment" and is "a hindrance" to performing surgery. However, to the patient, successful orthosis treatment may go on for years, without the attendant potential medical risks and disability of surgery. Many patients are quite pleased with this form of conservative treatment, others are not.

My first thoughts are, Mr/Mrs. Caf002, what you are doing wrong with your orthoses so that you are not achieving the same results that myself and many other podiatrists are achieving with Morton's extensions when treating hallux rigidus/limitus? If you have found these orthoses to be "a hindrance" and the rest of us have not found this to be the case, could it possibly be that you are not ordering or making these orthoses correctly?

Secondly, you say "Sorry guys" since you have found these orthoses to be "a hindrance". Are you sorry for us, sorry for yourself, or sorry for your own patients??

__________________
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
**************************************************

For those patients who have been resistent to morton extension, I have been ask the lab to continue the polyprop to the toes. With the orthosis uncovered I can then marked the standing position of the 1st digit and cut away the material that is not needed under the 2-5 MPJs proximal. As a result I am then let with a long more rigid extension that reachs to end of the hallux. This seems to reduce the dorsiflexion force at the 1st MPJ, more so than tradition mortons extensions. I have found that a rockersole also a benifical adjunct.

The key with any orthotic intervention is to have a clear aim as to what you are try to achieve-
So with a painful hallux limitus the aim with a morton's extension is to provide a fulcrum to allow toe-off with less force on the joint- a rocker within the shoe if you like. A rigid morton's extension is probably the most aggressive form of this, and can certainly be used with great effect- the only negative being that you would need to press a new shell if you felt that the extra support was needed after you had issued the devices.
A rocker soled shoe has a good chance of working also, but you are therefore much more limited in shoe choice- surely it is easier to have an insert that you can change from shoe to shoe, than only having certain modified shoe available to use.
I would suggest that the first thing that is needed however is the have the orthotic providing the best control possible to decrease the force under the joint- if you don't have this, you are putting the cart before the horse, and whether you use an extension or a rocker soled shoe, you are making life difficult for yourself.
Having said that- sometimes surgery is the only option.
Cheers

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

Pedorthic comment here: unlace the shoes, start relacing form the 2nd or 3rd eyelet to reduce stress across the dorsum. A new shoe out which needs a bit more design is the Velocy (sp?) which has a trenedous rocker however is a bit too pointed at the toe box for my liking. Hopefully they will work on that shortcoming.

Regards,
Freeman

Hi Sean - is this technique achieving the same end as a gait plate?

Chris

Yes and no.

Like a gait plate, I think the rigid morton's extension produces gait alteration rather than "supporting" the first mtpj. But, from what I remember in school, a gait plate should be worn in a very flexible shoe so as to produce irritation of the medial or lateral (depending on desired goal) and influence reactionary intoeing or outtoeing. I don't think the goal here is to cause pain, and I rarely see pain as a common complaint with the rigid morton's extension.

BTW, I think that the rigid morton's extension should have a different name since it's design and intention is different from what morton wanted to achieve with his original extension- please hold the obvious comments that that last statement prompts :P

Hi Williac,

I could the function would be similar or the same as gait plate. However, I have found if you ask the lab. to extend to orthosis distally, often if doesn't extend to the end of the 1st digit and does sit comfortable under the 1st digit. By extending the material to end of the digits then you can remove more accurately the excess, and hence support the 1st digit completely. This will limit the 1st MPJ ROM.

Hi Sean,
Sorry to go over old ground regarding your polyprop extension, (I only just read it),
1) Can you tell me exactly where you extend it to?
2) Poly thickness?
3) Any polyprop breaking at 1MPJ?
4) Pt comfort/discomfort
5) Is there any significant(whatever that means) gait changes.
The only reason why I ask #3 is because although I have tried something similar in principle with a steel shank, it almost always breaks (but brilliant results initially).
Regards
Con

The only reason why I ask #3 is because although I have tried something similar in principle with a steel shank, it almost always breaks (but brilliant results initially).


Have you tried carbon fibre? 3mm xt sprint works pretty well for Rigid ME's.

Ive tried allsorts of designs for this problem and truly believe the design to be patient specific.

In some of my older patients Ive used a shank dependent MD EVA orthotic with a full length carbon fibre insole (either on base of orthotic or sandwiched in the EVA).

Again, plenty of design suggestions here that would work fine on the right individual.

__________________
''The bottom line is too many people prescribe devices who haven't got the faintest idea of what they are doing. There are certain unscrupulous labs supporting this. There are too many people in it for the money.'' paraphrasing Simon Spooner

Reply quoted by Kevin Kirby
I will try inverting the orthosis and using a medial heel skive with minimal arch fill to try and supinate the foot so that the GRF is reduced plantar to the first metatarsal head. Over-supination of the foot by the orthosis, however, may cause increased late midstance pronation which will exacerbate the symptoms. Use at least a 3 mm thick Morton's extension on the orthosis.


What density of material do you use for the morton's extension? Is it an EVA or a Poron or similar material?

regards
Terry Troy

I use korex, which is a rubberized cork material, similar in density to medium density EVA.

__________________
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
**************************************************

Also worth adding a rocker sole type mod to the underside of the Mortons extension. I do this with Polyprop using a CAD system but you can just shape in HD EVA.

Phil

We all have patients with pain attributed to a supinated foot, in fact, frequently in patients with hallux rigidus it's the secondary pain from a compensating supination that brings them in, not the 1st MTPJ pain.
I'm curious as to the rationale in purposely supinating a foot as a treatment.
I realize it may help 1st MTPJ pian, but are we predisposing the patient to "other" future problems.
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

I would like to add three comments.

1. I am curious about the fixation of using a foot orthoses with a morton's extension for hallux rigidus. My first encounter with this type of device was for some one who had their hallux amputated!

2. The simplest device with a Morton's Extension is a ready made carbon fibre foot plate which is available in various grades of thickness and flexibility

3. A stiff soled shoe that has a decent rocker sole does wonders. Alternatively a shoe modification with a rocker sole, with the apex of the rocker place just proximally to the first mpj should also be considered

Cheers from Aus

Are there readily accessible carbon fibre foot plates in Australia? Or would you just supply an orthotic lab with a sizing & they supply?