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Maybe this is somewhat like trying to make the change from the laughable term "first ray hypermobility" to a scientifically definable term "decreased first ray dorsiflexion stiffness"...it is very painful for many podiatrists who are currently "comfortable" with their version of reality to change their "belief system".

I picked up on this statement from Kevin and I am curious to know the difference between these two descriptives. I am hopeful Kevin will elucidate his thoughts. What is the difference here and what are the clinical / surgical implications if there are real differences?

I have noted a surgical trend to move towards the Lapidus procedure in cases of "hypermobile 1st ray" contributing to hallux valgus. Some notebale surgeons dismiss in the surgical texts the hypermobile 1st ray as a rarity. Is this another modern myth? Is this trend just another surgical fad? What clinical evidence is there one way or the other?

Whilst on the topic of modern podiatric myths... who would like to produce a list?

There has been some wonderful reseach done on this subject by Andrew Fauth, PhD, at Penn State Biomechanics Lab for his Master's Thesis. Andy's work was published a few years ago and it really is a must read for anyone interested in first ray biomechanics (Fauth AR, Hamel AJ, Sharkey NA: In vitro measurements of first and second tarsometatarsal joint stiffness. J. Applied Biomechanics, 20 (1): 14-24, 2004).

After reading Andy's paper in J. Appl. Biom., I got to talk with Neil Sharkey, PhD (another biomechanics PhD at Penn State) at a seminar last year in Los Angeles about their paper. I got excited since I thought this paper finally was podiatry's solution to the problem with the poor term "first ray hypermobility". I had been thinking about this problem for the past 10 years and it wasn't until I read this paper that I finally started to see how using the concept of stiffness, a load-deformation characteristic of materials, would help us understand the first ray better. I think that "decreased first ray dorsiflexion stiffness" will be a vast improvement in terminology.

__________________
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

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I have a lot to say on this subject since I just spent at least 8 hours yesterday preparing a PowerPoint lecture titled "Biomechanics of the First Ray: First Ray Hypermobility vs Decreased First Ray Dorsiflexion Stiffness". However, I don't have a whole lot of time now to discuss these subjects.

First, try reading the paper that Tom Roukis and I wrote on the subject, and that should help answer some of your questions. http://www.biomech.com/printable/ind...leID=165700382

The main difference between the two terms is that first ray hypermobility is misleading, innaccurate, unscientific, and imprecise while decreased first ray dorsiflexion stiffness is precise, scientifically definable, and unambiguous.

The main problem with patients that have "first ray hypermobility" is not that the first ray moves too much. The main problem is that the first ray exerts too little force against the ground when it dorsiflexes a certain amount. Therefore, the first ray "moving too much" or having "hypermobility" has nothing to do with the problem of the first ray. The problem is too little dorsiflexion stiffness or, said another way, the problem is too much dorsiflexion compliance of the first ray.

Maybe if you have any more questions I will be able to free up some more time to answer them later.

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

See this thread:
http://www.podiatry-arena.com/podiat...read.php?t=797

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Kevin - forgive my ignorance, I would not argue with the noble motive to accurately ascribe proper terminology but does the 1st ray know about the name change and does he care? For practical purposes, in a clinical or surgical sense, whats the difference? (A rose by any other name is still a rose?) I have read another thread in which this subject was raised and it seems this quickly stirs up the podiatric raw nerve - my interpretation of this is the here and now is about altering the mind set, and then work out how this might affect treatment paradigms.

I seem to recall suggesting the same thing about the mid-tasal joint :) Despite all the research and our threorising on its function she still keeps on functioning just the same

__________________
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
This is where I am, where are you?

Craig

I have a motorcycle - its a she. I don't know why but 1st ray - somehow its a HE?!?

Dear Dieter

You wrote "a rose by any other name is still a rose"

That may be true but I would say the confusion comes when one of us thinks we are talking about a carnation.
Light and soft can have a similar meaning. light touch, soft touch. But not if you were talking about a light weight. soft weight makes no sense.
So when a word, like hypermobile, is used that describes a relative range of motion it makes no sense to use that word to describe the quality of that motion in terms of its resistive force. So more precise terminology will tend to give a more precise understanding when communicating with others, wouldn't you agree.

Anyway to continue on the Shakespeare theme (please forgive me Kevin)


Kevin K.---
'Tis but thy name that is my enemy;--
Thou art thyself, though not a hypermobile 1st ray
What's hypermobile? It is nor hand, nor foot,
Nor arm, nor face, nor any other part
Belonging to Biomechanics. O, be some other name!
What's in a name? that which we call a rose
By any other name would smell as sweet;
So hypermobile 1st ray would, were he not hypermobile 1st ray call'd,
Retain that dear perfection which he owes
Without that title---hypermobile 1st ray:, doff thy name;
And for that name, which is no part of thee,
Accept my more precise terminology.

1st Ray.---
I take thee at thy word:
Call me but '1st ray Increased dorsiflexion stiffness, and I'll be new baptiz'd;
Henceforth I never will be hypermobile. :) :)

And I bid thee good day, Dave Smith

R.I.P.

David.Congratulations with the poem.
I think there will always be a better way in doing things and so might terminology go on the change wave.

David is right here. If we, as a profession, are to advance in our knowledge of the biomechanics of the foot and lower extremity, then the terminology we use to describe the mechanical phenomena of the foot and lower extremity must be as precise as possible. However, if we, as a profession, are content to speak in clinical terms that are imprecise and have ambiguous definitions such as "first ray hypermobility", "locking of the midtarsal joint", or "hyperpronation", then we will stagnate while other professions carry the banner of scientific accuracy and advanced biomechanical knowledge far ahead of us.

I would rather march ahead with those that desire more accurate, more scientific, and less ambiguous terminology, than sit back with those that have little interest in advancing their knowledge and improving their terminology. Time will prove that those that are considered by the podiatric profession as having advanced knowledge in foot biomechanics will stop using the term "first ray hypermobility" and start using a more scientifically accurate term such as "decreased first ray dorsiflexion stiffness".

By the way David, could you put the hypermobility words into the lyrics of a Beatles song for me? I understand the Beatles better than Shakespeare.

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

Kevin

This is the Romeo and Juliet scene
Juliet.
'Tis but thy name that is my enemy;--
Thou art thyself, though not a Montague.
What's Montague? It is nor hand, nor foot,
Nor arm, nor face, nor any other part
Belonging to a man. O, be some other name!
What's in a name? that which we call a rose
By any other name would smell as sweet;
So Romeo would, were he not Romeo call'd,
Retain that dear perfection which he owes
Without that title:--Romeo, doff thy name;
And for that name, which is no part of thee,
Take all myself.

Romeo.
I take thee at thy word:
Call me but love, and I'll be new baptiz'd;
Henceforth I never will be Romeo.

and for those who understand modern english better (all of us) my rewording for Hypermobile 1st ray version.

Kevin K.--- Speaking to 1st ray--
It is only your name that offends me;--
you are yourself (a collection of bones and joints), not a name such as hypermobile.
What's hypermobile? It is neither hand, nor foot,
nor arm, nor face, nor any other part belonging to Modern Biomechanics.
Please, (for the sake of precise communication) use some other name!
What's in a name? you are still you, 1st ray, whatever name you are called.(you won't change)
so even though you where not called hypermobile you would still be our old friend, the 1st ray.
And retain the qualities we love you for
even without that title---hypermobile 1st ray:, so cast off that name;
And in place of that name, which really is not right for you,
Accept my more precise terminology. (1st Ray decreased dorsiflexion stiffness)

1st Ray.---to Kevin K
I understand your reasoning:
Please, rename me, "1st ray Decreased dorsiflexion stiffness", and I will be reborn in the true light
Never again will I be hypermobile.

Hope that is more clear, cheers Dave Smith.

Thanks for the translation, Dave.

Last year while lecturing in England, my wife, son and I all visited Stratford-upon-Avon and Mr. Shakespeare's birthplace. Had a wonderful time there and even went for a motor boat ride on the Avon. Lovely!

In high school, I did have a full semester course on Shakespeare and luckily my teacher was able to translate and put his plays in perspective for us California teenagers quite well. I'm attaching a drawing I did of the Globe Theater for my Shakespeare class when I was a mere long-haired lad of seventeen.

So even though I need help in better understanding the works of one of England's finest, I do greatly appreciate his ability to put words together in the telling of stories.

Attached Images

Globe Theater Small.jpg (82.1 KB, 530 views)

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

Kevin

Hmm! Very impressive. You were a stickler for detail even eh!

Cheers Dave

Guys - yes I KNOW language is important but my original question remains unanswered, and as we are talking Shaskespeare, and flowers andwhatever else I will assume the renaming excercise has so far resulted in no new understanding or applied knowledge. And this is what I was really interested to know......

Dieter:

If a clinician uses the term "hypermobile" to describe the first ray of a patient, doesn't that then imply that the first ray of the patient moves more than normal when their foot pronates? If not, then please tell me what a "hypermobile first ray" is supposed to mean. I believe that if any clinician uses the term "first ray hypermobility", then this is what they are basically saying: the first ray dorsiflexes too much while functioning on the weightbearing surface.

However, what I am proposing is that the clinician now use the term "decreased dorsiflexion stiffness" to describe the mechanical function of the first ray of that same patient. In that way, when anyone hears or reads their description of the first ray mechanics of the patient, that it will be clearly understood that the patient's first ray is not necessarily moving too much, but that it is exerting less force on the ground than it should for the given amount of dorsiflexion motion it has made. These are very important distinctions to be made and I believe it represents a paradigm shift in the understanding of first ray and lesser ray function.

Would you not agree that this represents a "new understanding" of first ray biomechanics and better "applied knowledge" of first ray function?

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

Two Things here Deiter.
First language is a cornerstone of understanding and knowledge. Without the power of sophisticated language, and because of this, the Neanderthal Man was suceeded by a smaller brained possibly less inteligent human that had the power of speech to communicate ideas and knowledge more precisely. The more sophisticated the language became the more 'intelligent', as a race, modern humans became.
If you consider the extracts from Romeo and Juliet you will understand that, although my version is humerous, these words are very poignant to this argument. Juliet sees Romeo for the man he is not for his name which, for others, who only know him by his name (Montague) changes the mans character in their minds because of his family ties and reputation. This misconception comes because of a name and not because the character of the man which would be the same whatever he were called. So therfore some can not trully or fully understand the man (Romeo).
The same could be said for the 1st Ray, as indeed I have in my version of the scene extract, Those who study 1st ray will know its characteristics well but those who only know is characteristics by its name may well have a misconception about those characteristics. So to understand the precise nature we must have a precise name.
This Dieter, of course, will not change your understanding of 1st Ray since you allready know him well (by any name) and this is the basis of your argument I think.


Secondly, if you wanted to apply your knowledge of 1st ray to designing a prosthetic, for instance, then in your attempts to communicate with engineers you would need to use terminology that would be both common and clear to both parties and hypermobile would not relate in any way to describing the stiffness/resistance to deflection or deformation required in its constrution and function. So then you may fail your task for the sake of a word.

Have a good day Dave Smith

Quite probably. But the point I am failing to convey is that I have no issues with the proposed concept of stiffness. I like stiffness. I do.

The principal of abnormal 1st ray excursion is 'rooted' in biomechnical texts of podiatric origin. Do we have a large data base of normal measurments / function to draw comparisons? What is the normal excursional range of the 1st ray? Who decreed any specific range is normal or abnormal? How was this measured? I recall a study claiming under 'normal' circumstances (the asymptomatic foot) the 1st metatarsal head receives a loading pressure twice that of 2-5.


Sure

Yes I would Kevin. I am sure paradigm shifts are important if the art of foot mechanics is to progress and evolve into a science, as older theories fail to live up to expectations and scientific probing.

How can we know when there is insufficient stiffness? Is there as yet a database of normal? How do we measure this? How do we recognize normal / abnormal?

If there is a callous sub 2nd metatarsal, 2nd MPJ capsulitis/plantar plate tear, functional hallux limitus, hallux abucto valgus, or other pathology caused by excessive STJ pronation moments (i.e. posterior tibial tendinitis) then one of the causes of this could be decreased first ray dorsiflexion stiffness. Of course, this does not mean that the decreased first ray stiffness is a primary etiology, since the decreased first ray dorsiflexion stiffness could have also been caused by chronic overload of the medial column plantar ligaments/fascia due to excessive STJ pronation moments.

I don't know of any database for normal of first ray stiffness or for any of the older foot and lower extremity measurement parameter that have been taught over the past 30 years in podiatry schools around the world. Dieter, is there a database as of yet of subtalar joint range of motion??

We may measure passive first ray dorsiflexion stiffness by assessing the amount the first metatarsal head moves to varying dorsiflexion loading forces, instead of just one loading force. For example, one could first push up on the first metatarsal head with 5 pounds of force, then 10 pounds and then 15 pounds and see how it responds. Do the people with sesamoiditis show a different response than the people with sub second callouses?

We are in the infancy of thinking this way. However, your questions, Dieter, are the next logical steps we should be taking....if anyone else wants to take the baton to do so.

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

I suspect that this an area where pressure mats which can show first metatrasal head loading forces (via ground reaction force) in late midstance through propulsion really may provide a clinically relevant answer to this question. Such results would be biased by a midtarsal joint that enters propulsion not in the fully locked and pronated position which would decrese ground reaction force under the first metatarsal head. I am not sure how to separate those two issues if such pressure mats are to be used for studies.
Ed Davis, DPM

Role of First Ray Hypermobility in the Outcome of the Hohmann and the Lapidus Procedure
A Prospective, Randomized Trial Involving One Hundred and One Feet
Frank W.M. Faber, MD1, Paul G.H. Mulder, PhD2 and Jan A.N. Verhaar, MD, PhD3
1 Department of Orthopaedic Surgery, Leyenburg Hospital, Postbox 40551, 2504 LN The Hague, The Netherlands. E-mail address: f.faber@leyenburg-ziekenhuis.nl
2 Department of Epidemiology and Biostatistics, Erasmus University Rotterdam, Postbox 1738, 3000 DR, Rotterdam, The Netherlands
3 Department of Orthopaedic Surgery, Erasmus Medical Center, Dr. Molewaterplein 60, 3015 GE, Rotterdam, The Netherlands


Investigation performed at the Department of Orthopaedic Surgery, Leyenburg Hospital, The Hague, The Netherlands

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.


Abstract
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References


Background: The role of hypermobility of the first tarsometatarsal joint in the etiology of hallux valgus deformity is controversial. Consequently, the need to include an arthrodesis of this joint in the surgical treatment of hallux valgus has been questioned. We designed a study to evaluate the role of arthrodesis of the first tarsometatarsal joint on the outcome of surgical treatment of hallux valgus.

Methods: A prospective, blinded, randomized study was performed to compare the results of a distal osteotomy of the first metatarsal (the Hohmann procedure) with those of an arthrodesis of the first tarsometatarsal joint combined with a soft-tissue procedure of the first metatarsophalangeal joint (the Lapidus procedure) for correction of a symptomatic hallux valgus deformity. One hundred and one feet of eighty-seven patients were included in the study. Fifty feet had a Hohmann procedure, and fifty-one had a Lapidus procedure. The mobility of the first tarsometatarsal joint was assessed in the preoperative clinical examination. On the basis of this examination, two subgroups were identified: sixty-eight feet with a hypermobile first tarsometatarsal joint and thirty-three feet with a nonhypermobile first tarsometatarsal joint. The patients were assessed clinically and radiographically at two years after the operation.

Results: There was a significant improvement in the score on the great toe metatarsophalangeal-interphalangeal scale of the American Orthopaedic Foot and Ankle Society and in the pain score following both procedures (p < 0.001). With the numbers available, no significant difference between the two procedures or between the subgroups of feet with a hypermobile first tarsometatarsal joint and those with a nonhypermobile joint could be identified. The patient satisfaction rating did not differ either between the two procedures or between the two subgroups. The radiographic results of the two methods were also similar, except for shortening of the first metatarsal, which was significantly greater (p < 0.001) in the Hohmann group, and plantar flexion of the first metatarsal, which was greater in the Lapidus group.

Conclusions: These short-term results were satisfactory and were comparable with those in previous isolated reports on these two procedures. As no significant differences between the two procedures or between the two subgroups (feet with a hypermobile first tarsometatarsal joint and those with a nonhypermobile joint) were found on clinical assessment, the theory that patients with hallux valgus and a hypermobile first tarsometatarsal joint should be managed with a Lapidus procedure was not supported.

http://www.ejbjs.org/cgi/content/full/86/3/486

Re hypermobile 1st ray:Is this a chicken-egg theory?A plantarflexed 1st MPJ seems to be the major villain regarding foot pathologies,for example,diabetic ulcers under the MPJ.So I guess my question is:Would you not correct the plantarflexion?It is nice to notice the hypermobility and other pronation issues,but the surgical procedures appear to primarily address the plantarflexion issues.