Adducted hallux

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I recently saw a 3 and a half year old in clinic with a normal foot profile but with an adducted hallux on both feet. Child was pain free with no footwear problems.

Parental concern made the child come to clinic as they believed he was intoeing. The rest of his foot was straight except for the hallux. The hallux was flexible and easily abducted and adducted further.

I did not carry out any treatment at this time but wondered what peoples thoughts were on this and if there was anything around on future problems this could cause? Help would be appreciated.

Thanks

Matthew

 

Gday

Could be Congenital Hallux Varus. Xrays when she gets older would confirm by absence of Fibular sesamoid. Also check innersole in shoe and see if area under Distal phalanx of hallux is worn and compressed. Pts with this tend to claw their big toes, havnt figured out mechanics of why yet but I presume that as normal
1st MPJ function is impeded by structure of the joint, a FHL results and as weight shifts distaly under the Hallux during terminaol stance, it locks and the dorsal force usually Dorsi flexing the 1st MPJ applies a deformation force to the innersole?

In my experience ask mum and/or dad to take their shoes off and have a look at their little piggies, :wacko: I beleive it can be an automsomal dominant trait.

Regards

mRt

 

Cheers for that. Mother had exactly the same problem. Would you do anything for this to prevent possible future problems? Mother has no problems with hers so theres no parental concern regarding what might happen in the future.

Thanks again

Matthew

 

With my very limited experience I would say that there are some possible issues that may arise, mainly to do with fualty 1st MPJ function, inability to iitiate windlass etc.

Out of interest, could you aquire a family hx and check to see if its predominantly on the mothers side. Does the mother and duaghter both have hypertrophied abductor hallucis muscle belly's? Please check the innersoles in mums joggers and let me know if they are worn under the distal Phalanx of the Hallux. Also check nanna's foot for callous patterns, O/A Degen, foot pathology if she HLXADDVLGS as well. This will give you a truer indication of possible future issues that come with the mechanics of this foot. Be sure to ask mum and nanna about their knee's and hX of knee pain.
Another isue that may arise is issues with getting appropriatly fitting F/W.

I wonder if at this age you could trial a straight lasted shoe if it was reducable? I guess it wouldnt matter anyway though as the deficit in mechanical advantage due to the absent fibular sesamoid will just pull the te back into the same orientation.

I presume you have ruled out met adductus? This needs to be ruled out asap as conventional wisdom seems to dictate that it can only be treated conservativly prior to age 4. Look for prominent styloid and and C shape foot. I know you probably dont need to be reminded about this anyway, so sorry if I sound patronising.

MrT

 

Cheers Mr T.

At first glance my initial thoughts were met adductus, but once i actually looked at the foot i realised it wasnt. Mother has no probs but she is not into sporting activity. As for the Nan? Not sure she has one so might not go there.

Straight last shoe or one that doesnt deviate may help but then it may rub i suppose.

Ill check it out on review. Thanks for your input mate. appreciated.

 

Matthew:

Isolated tightness in the abductor hallucis muscle/tendon unit may cause an adducted hallux deformity (i.e. hallux varus) in a child. I would put the child into shoes that forced the hallux straight, as long as the medial hallux isn't being irritated by the shoe pressure. If it is difficult for the child to fit normal shoegear, a surgical lengthening of the abductor hallucis tendon can be performed. However, if the mother isn't too concerned since she never had problems with a similar deformity, then certainly trying to have shoes stretch out the tight muscle/tendon while the child is young seems like the best option at this time.

Hope this helps.

 

http://www.emedicine.com/orthoped/TOPIC127.HTM

http://www.ocpm.edu/hallux/HV chapter 22-Hallux Varus.pdf

 

Simon

Excellent

:good:

Dave

 

Cheers guys, all very helpful.

Kevin, Do you see much surgery done on these types of hallux deformity? And do you think localised mobilisations/ stretching would be of benefit if done by the parents?

Cheers again

Matthew

 

I feel a bit silly now, but in my defence I did preface my statements with 'in my limited experience'. I saw a family recently who seemed to have the deformity on the mothers side gong back someway, seemingly isolated to the ladies in thye family. Xrays demonstrated absence of the fibular sesamoid, and I attributed the Varus alignment due to imbalances cuased by one of the flexor tendons having the mechanical advantage of a sesamoid and the other not. All of the ladies in this family also demonstrated swollen abductor hallucis muscles to go along with their ungainly big piggies.

My queeries about knee pathology were only an attempt to elucidate if the patho mechanics (if indeed there are any) of this foot in your patient matched what I have obseved anecdotelly in my patients. I dispensed an orthosis with met dome and rather proximal 1st ray C/O (met cunieform jnt) and advised a straight lasted supportive shoe. This reduced the duaghters bi lateral knee pain by about 80%.

Very interesting that this foot would be considered the norm, in regards morphology for mankind had we not ushered in the age of footwear. Bloody Nike!! Still, where would mankind be without the shock attenuatting wonders of Brooks Hyrdro flow, Nike air and Asics Gel (Dangles bait).

MrT

If I could figure out how to do it, and assumming it was of interest to any one, I really should post up some xrays. Can anyone enlighten me as to whats involved in doing this?

 

I don't know why you feel silly? This may be worth writing up for a paper. Start by drawing up and analysing the pedigree.

 

Matthew:

I have never done this surgery, but have attended lectures by surgeons who have done this surgery with good success. Actually, rather than mobilizations/stretching I would first recommend wearing shoes (as I mentioned earlier) that provided as much stretch to the abductor hallucis tendon as possible in order to try and swing the hallux over toward the 2nd digit, without causing medial hallux skin irritation or discomfort. The abductor hallucis muscle will pull the hardest on the hallux in late midstance and wearing shoes that straighten the hallux will not only work for a longer period of time during the day than mobilizations/manual stretching but will probably work with just as much, if not more, force on the hallux.

Good discussion.:drinks

 

Thanks Kevin,

I will try that. I suppose some of my concern in footwear is that you never know exactly what is going on in the shoe.

Also i would not know how much force would be added to the hallux and whether it could add too much and abduct too far. I suppose regular reviews and good parental advice is the key.

Cheers

Matthew