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Juvenile HAV

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  #1  
Old 10th November 2007, 12:31 PM
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Smile Juvenile HAV

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Hi everyone

What's the current thoughts on treating juvenile HAV with orthoses. I support the use of a 1st ray cut out and arch fill to reduce subluxation at the 1st MTPJ. I am not not convinced by Kilmartins paper (1994), as he is surely dorsiflexing the 1st ray, which must exacerbate the problem, with the orthoses he used!

Any thoughts??

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Old 10th November 2007, 03:02 PM
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Default Re: Juvenile HAV

Related thread:
Hemiepiphyseodesis of metatarsal in juvenile HAV
Hallux Valgus Night Splints...
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Old 10th November 2007, 04:34 PM
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Default Re: Hallux Valgus Night Splints...

I am a little dubious of Kilmartins paper on juvenile HAV treatment by orthoses. He did not allow the first ray to plantarflex. This would likely cause jamming and subluxation of the 1st MTPJ. As a plantar or dorsiflexed first ray would seem to contribute to the pathology (as indeed mentined by Kilmartin in an earlier paper), surley an orthoses with a first ray cut out would benefit this condition.

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Old 10th November 2007, 05:25 PM
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Default Re: Hallux Valgus Night Splints...

Quote:
Originally Posted by robcox View Post
He did not allow the first ray to plantarflex.
We don't know if that was the case or not. Its widely suggested that is the case, but we just do not know. Those who do not like the outcomes of the Kilmartin et al study like to claim that, but I would like to know how they know it is the case. Kilmartin never published any work on how the foot orthoses he used affected first ray function (that does not mean they didn't).
Quote:
This would likely cause jamming and subluxation of the 1st MTPJ. As a plantar or dorsiflexed first ray would seem to contribute to the pathology (as indeed mentined by Kilmartin in an earlier paper), surley an orthoses with a first ray cut out would benefit this condition.
We don't know if that is the case or not. Theoretically it could be the case, but no one has actually done any outcome work to show it.
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Old 10th November 2007, 05:31 PM
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Default Re: Juvenile HAV

There is a bit of a parallel discussion going on here, so the last two messages above are copied from another thread on Hallux Valgus Night Splints... below...
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Old 11th November 2007, 05:34 AM
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Default Re: Hallux Valgus Night Splints...

Thanks for this Craig.
Can I ask you then what conservative measures, if any, you use for this condition?

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Rob
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Old 11th November 2007, 05:54 AM
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Default Re: Juvenile HAV

I would be hard pushed to keep a straight face when trying to convince parents that they need custom made orthotics for their kids HAV. I would be prepared to use one if there is more going on other than the HAV to justify them (eg co-morbidity such as severe pronated foot). Its easier to justify the night splints due to the evidence we have for them.

I certainly explain the evidence and the theory to them as best I can and let them decide.

Even if foot orthoses were indicated, how long a period(s) of non-compliance are likely to occur when no symptoms are present? Will that period of non-compliance be sufficient for any good to be undone.
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Old 11th November 2007, 06:02 AM
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Default Re: Hallux Valgus Night Splints...

Quote:
Originally Posted by Craig Payne View Post
We don't know if that was the case or not. Its widely suggested that is the case, but we just do not know. Those who do not like the outcomes of the Kilmartin et al study like to claim that, but I would like to know how they know it is the case. Kilmartin never published any work on how the foot orthoses he used affected first ray function (that does not mean they didn't).We don't know if that is the case or not. Theoretically it could be the case, but no one has actually done any outcome work to show it.
Actually Kilmartin did look at this in his paper here:
http://www.japmaonline.org/cgi/conte...tract/81/8/414

We know that he used a Root type orthoses in his prospective trial.

Rob's argument once again highlights the limitations of orthoses research- what did the Kilmartin study actually test? However Rob, I would also warn that you have little solid ground for your contention that a 1st ray cut-out and arch fill makes for an efficacious treatment of juvenile hallux valgus.
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Old 11th November 2007, 07:08 AM
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Default Re: Hallux Valgus Night Splints...

Thanks Simon,

I have quickly realised that there is no evidence on the 1st ray cut-out and its affect on HAV development; But in your view (or anyone who is happy to give one), do you think that it should be contra-indicated in juvenilles with HAV and a PF 1st ray? Especially as it seems to be fairly widely accepted that this stuctural variation (which leads to jamming at the 1st MTPJ)is an aetiology to HAV.

With regards to the night spints, I think the jury is out on this one (as with most things)!. Indeed, a Cochrane review by J Ferrari et al:

http://mrw.interscience.wiley.com/co...64/pdf_fs.html

state that there is no strong eveidence to support the use of night splints.

What about a toe prop to maintain the 2nd toe as a butress to the 1st??

Rob
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Old 11th November 2007, 07:38 AM
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Default Re: Hallux Valgus Night Splints...

Quote:
Originally Posted by robcox View Post
Thanks Simon,

I have quickly realised that there is no evidence on the 1st ray cut-out and its affect on HAV development; But in your view (or anyone who is happy to give one), do you think that it should be contra-indicated in juvenilles with HAV and a PF 1st ray? Especially as it seems to be fairly widely accepted that this stuctural variation (which leads to jamming at the 1st MTPJ)is an aetiology to HAV.
NO

Quote:
Originally Posted by robcox View Post
With regards to the night spints, I think the jury is out on this one (as with most things)!. Indeed, a Cochrane review by J Ferrari et al:

http://mrw.interscience.wiley.com/co...64/pdf_fs.html

state that there is no strong eveidence to support the use of night splints.
Not sure of the date when Jill carried out her Cochrane review. However, we do now have two reasonable studies which have demonstrated positive outcomes. Two more than we have for many of our interventions.

Quote:
Originally Posted by robcox View Post
What about a toe prop to maintain the 2nd toe as a butress to the 1st??
Not my cup of tea, but never seen a trial on this.
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Old 11th November 2007, 08:13 AM
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Default Re: Hallux Valgus Night Splints...

The review was in 2004. Which papers support the use of the night splint?
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Old 11th November 2007, 09:00 AM
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Default Re: Hallux Valgus Night Splints...

I am not sure that foot orthoses, even if they are well designed, have a great potential to take all the deforming forces away from the progression of hallux abducto valgus (HAV) deformity. In addition, I have never seen a foot orthosis cause a reversal of a bunion deformity. In patients with a high degree of metatarsus adductus deformity, a first metatarsal head with a small radius of curvature (on AP radiograph), and a more pronated foot, there is probably no foot orthosis that will prevent HAV deformity from developing. Some people will develop HAV regardless of what we do, short of surgery.

However, I have many patients with painful 1st MPJs also with HAV deformity, that are made asymptomatic with foot orthoses, as long as they wear shoes that don't irritate their bunion bump. Of course, in these patients, the clinical improvement in pain that results from removing the pathological forces/moments from the 1st MPJ with orthoses is fairly rapid (i.e. weeks). But for a child or adult with a progressive HAV deformity, I am happy if the orthosis has just slowed the progression of the deformity over the subsequent years.

Until an orthosis can exert more transverse plane forces on the first metatarsal and hallux, like a night splint does, foot orthoses will continue to only help the milder cases of HAV deformity. I don't see much chance in accomplishing this currently, especially in our Western Society where women's shoes are viewed more as a fashion accessory rather than an important clothing article that should improve comfort and function during weightbearing activities, and not shape the foot into an unnatural appearance for the purpose of vanity and fashion.
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Old 11th November 2007, 09:08 AM
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Default Re: Hallux Valgus Night Splints...

Hi Kevin,

thanks for your reply.

Are you convinced that orthosis can slow down the progression of HAV in juveniles? Have you seen this at first hand?

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Rob
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Old 11th November 2007, 09:11 AM
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Default Re: Hallux Valgus Night Splints...

Quote:
Originally Posted by robcox View Post
The review was in 2004. Which papers support the use of the night splint?

Juvenile hallux valgus. A conservative approach to treatment
JA Groiso
The Journal of Bone and Joint Surgery, Vol 74, Issue 9 1367-1374


Conservative treatment of juvenile hallux
valgus - A seven-year prospective study
Andrew J H Macfarlane, T E Kilmartin
British Journal of Podiatry November 2004 ; 7 (4): 101-105
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Old 11th November 2007, 10:03 AM
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Default Re: Hallux Valgus Night Splints...

Quote:
Originally Posted by robcox View Post
Hi Kevin,

thanks for your reply.

Are you convinced that orthosis can slow down the progression of HAV in juveniles? Have you seen this at first hand?

Regards

Rob
Rob:

That is a difficult question to answer since I can only give you my clinical observations. Theoretically, it makes sense that properly designed foot orthoses may be able to slow down the progression of milder HAV deformities. However, I have never followed a patient before receiving orthoses, taken serial radiographs or measurements, made them orthoses, and them followed them again over a period of years, taking serial radiographs or measurements after dispensing of their orthoses. My best clinical guess is that after a certain angular deformity of first intermetatarsal angle and hallux valgus angle has been reached, foot orthoses have very little chance of reversing or slowing down the progression of HAV. Dr. Mert Root also lectured on this 20+ years ago, stating that once the intermetatarsal angle (IMA) was large enough (I forget the numerical value of IMA he mentioned), foot orthoses won't help and surgery was required. I basically agree with Dr. Root on this point.
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Old 11th November 2007, 10:15 AM
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Default Re: Hallux Valgus Night Splints...

Thanks Kevin:

can I ask, based on your previous response would you issue an orthosis for patients with juvenile HAV, or does this depend on various factors, such as the stage of the deformity and any co-morbidities?

I had a patient (young female) with juvenie HAV and marked planatarflexed 1st's. Do you think an orthoses with a 1st ray cut out and some pronatory control will do any harm (in your experience). I am just conscious of Kilmartins paper (1994).

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Old 11th November 2007, 10:23 AM
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Default Re: Hallux Valgus Night Splints...

Quote:
Originally Posted by robcox View Post
Thanks Kevin:

can I ask, based on your previous response would you issue an orthosis for patients with juvenile HAV, or does this depend on various factors, such as the stage of the deformity and any co-morbidities?

I had a patient (young female) with juvenie HAV and marked planatarflexed 1st's. Do you think an orthoses with a 1st ray cut out and some pronatory control will do any harm (in your experience). I am just conscious of Kilmartins paper (1994).

Rob
Rob,

Did Kilmartin's paper conclude that orthoses did harm?

BTW In case you don't know I was Kilmartin's research assistant. He supervised my PhD on Hallux valgus :p
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Old 11th November 2007, 10:33 AM
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Default Re: Hallux Valgus Night Splints...

No I didn't know that!!

Yes the paper concluded that the orthoses used increase the rate of the condition.


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Old 11th November 2007, 10:33 AM
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Default Re: Hallux Valgus Night Splints...

Quote:
Originally Posted by robcox View Post
Thanks Kevin:

can I ask, based on your previous response would you issue an orthosis for patients with juvenile HAV, or does this depend on various factors, such as the stage of the deformity and any co-morbidities?

I had a patient (young female) with juvenie HAV and marked planatarflexed 1st's. Do you think an orthoses with a 1st ray cut out and some pronatory control will do any harm (in your experience). I am just conscious of Kilmartins paper (1994).

Rob
I would design the orthosis to exert decrease STJ pronation, decrease MLA flattening and increase first ray plantarflexion, as you have suggested above. I would have no problem making this patient orthoses with the hopes it would slow down progression of HAV.
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Old 11th November 2007, 10:46 AM
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Default Re: Hallux Valgus Night Splints...

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No I didn't know that!!

Yes the paper concluded that the orthoses used increase the rate of the condition.


Rob
Did he really, my memory ain't what it once was. Must pull that paper and re-read it. As I recall from the analyses presented, I think this was perhaps a little overstated. Like Kevin, my thoughts on hallux valgus these days are that it is essentially a dysfunction of the windlass mechanism so I try to offload the first MTPJ and medial column using valgus forefoot posting and cut-outs. I wouldn't be losing too much sleep over your clinical decision making here.
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Old 11th November 2007, 10:47 AM
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Default Re: Hallux Valgus Night Splints...

Thanks again Kevin. That's music to my ears!
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Old 11th November 2007, 03:20 PM
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Default Re: Hallux Valgus Night Splints...

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Originally Posted by Simon Spooner View Post
Actually Kilmartin did look at this in his paper here:
http://www.japmaonline.org/cgi/conte...tract/81/8/414

We know that he used a Root type orthoses in his prospective trial.
What I meant was he did not do any assessment of the biomechanical function of the devices used in the study on the subjects in the study. It rarely get done. One of the criticisms of the Landorf et al study was they published no data on the biomechanical effects of the different devices, especially the placebo device (I do not agree with the criticism as I have seen and touched the pacebo used in that study)

We currently up to subect 180 in a RCT of lateral wedges vs soft support for medial knee OA. We got vicon data on all and can be confident when we state exactly the effect of the "placebo" was on the knee --- it is especially true now that a lot have finished the 12 month follow up and are asking where they can buy the "placebo" from as it worked so well - we will have kinetic and kinematic data on these people to know exactly what was happening mechanicall with the "placebo". It was this kind of data as to what exactly mechanically was happening with the foot orthoses in the Kilmartin study that I was refering to.
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Old 12th November 2007, 01:41 AM
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Default Re: Hallux Valgus Night Splints...

Craig,

I see where you are coming from. Thanks for that.

When will your results for the trial on orthoses for medial OA be available? - Sounds interesting!

Regards

Rob
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Old 12th November 2007, 01:49 AM
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Default Re: Hallux Valgus Night Splints...

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When will your results for the trial on orthoses for medial OA be available? - Sounds interesting!
We still recruiting the last 20 or so subjects and they are all being followed for 12 months, so it will be a while. In the meantime, see this: Lateral foot wedging for medial knee OA
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Old 12th November 2007, 02:06 PM
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Default Re: Hallux Valgus Night Splints...

Thanks craig! Looks like another nights reading in front of the lap-top!

Rob
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