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1st MPJ Examination

Discussion in 'General Issues and Discussion Forum' started by Lee, Apr 1, 2008.

  1. Lee

    Lee Active Member

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    Just wondering what clinical examination of 1st metatarsophalangeal joint function is commonly practised out there prior to performing your interventions? For example, do you check passive non-weightbearing maximum toe dorsiflexion prior to fitting an orthosis or doing a cheilectomy, etc? Anyone doing any other clinical tests (along with radiology &/ or gait analysis) ?
  2. Non-weightbearing active, passive, resisted movements and accessories. Weightbearing- Jacks. Occasionally- sagittal plane video or O'Brien goniometer during gait.
  3. Lee

    Lee Active Member

    Cheers Simon,

    Accessories? Do you mean checking for extra sesamoids or assaulting the joint with hairclips, handbags and suchlike? ;)

    How do the aforementioned clinical tests affect your treatment choice for the patient? For example, the static passive ROM I mentioned previously - if we are to believe Root's book, we need approx 65 degrees dorsiflexion available at the joint for normal dynamic function and this can be judged by performing a non-weightbearing examination. If it's less than 65 degrees, how does this change our treatment? I realise I'm talking about a clinical exam in isolation and many other factors come into play, but what potential treatment options are available for people with 30-65 degrees of dorsiflexion available at the joint in this test? How would your orthosis, surgery, etc... differ in a patient that had >65 degrees dorsiflexion, 30-65 degrees, 0-30 degrees?

    Also, where did you get your O'brien goniometer?

  4. Asher

    Asher Well-Known Member

    Hi Lee,

    So what you are saying is if there is a structural hallux limitus, what do you do different compared to if there was 65 degrees dorsiflexion.

    I can tell you my thoughts on conservative management:

    If the 1st MPJ is symptomatic, I want to try and get what range we have got to be of good quality. Its not always the case but poor 1st MPJ mechanics (inadequate windlass mechanism) may have been the cause of the hallux limitus. So I try all the things that have been spoken about in depth here on Podiatry Arena, to promote the windlass.

    I am mindful though that producing better windlass function means demanding more 1st MPJ dorsiflexion (plantarflexion of 1st metatarsal / dorsiflexion of proximal phalanx) and can sometimes make the symptoms worse. So I always have a bit of a trial to see which way its going to go. I guess it depends on what range of 1st MPJ dorsiflexion you have got to work with and the degree of degenerative change at the joint. When there is very little or no dorsiflexion range, I'm not looking to get the windlass working basically because it can't. Actually preventing any 1st MPJ dorsiflexion may be the aim.

    The same goes for when the 1st MPJ isn't symptomatic - so either treating a symptom elsewhere (which will often involve maximising function of the 1st MPJ) or treating the asymptomatic structural hallux limitus with the intention of trying to halt its progression - I have the same things in mind.

  5. Lee

    Lee Active Member

    Thanks for the reply Rebecca,

    Regarding the above quote - sort of. I'm interested in the variety of different clinical tests of 1st MPJ (and 1st Ray) function (both weightbearing and non-weightbearing, static and dynamic) and their bearing on what we actually endup doing to our symptomatic patients, and most importantly - why? If we take the 65 degrees dorsiflexion chestnut - we use a simple test of maximum dorsiflexion available in a static examination, non-weightbearing and conclude that if the patient in front of us has more than 65 degrees available in this condition, they will have normal dynamic function at the joint. If any limitation in dorsiflexion occurs dynamically, this is classed as functional hallux limitus. So our treatment of the patient is then affected by this examination, in combination with our dynamic assessment, whereby we attempt to address whatever factor is contributing to the altered dynamic function of the joint. For example, you might prescribe an orthosis with a first ray cut out, kinetic wedge, etc... in order to address this factor that would then have a positive result on the amount of dorsiflexion available at the 1st MPJ and restore normal function.

    For the surgeons out there - what clinical tests do you use in your pre-op work up? Maximum dorsiflexion non-weightbearing? How about other tests, also in hallux valgus (track bound or concertina tests for example)?

    Is anyone using these 'objective' measures of joint function as an outcome measure? It's obvious that we all attempt to attain symptomatic relief, but any biomechanics or surgery text you read will extoll the virtues of improving function via each intervention as well. I'd like to know how everyone assesses this function pre and post intervention and how we can improve these measurements and potentially the interventions.

  6. Scorpio622

    Scorpio622 Active Member

    Things I commonly do:

    1) Observe and sometimes measure maximum passive dorsiflexion with metatarsal loaded and unloaded- noting difference for obvious reasons.

    2) Axial grind test- compression with rotation in resting position

    3) Toe raise or lunge test- looking for pain, limitation, IPJ/lesser MPJ compensation
  7. Accessory movements, e.g. dorso-plantar glide, long axis varus/ valgus rotation, abb- adduction.

    Actually dynamic RoM is usually reported lower than the 65 degrees "normal" reported by Root ( See Catherine Smith, Simon K. Spooner, and John Alan Fletton: The Effect of 5-Degree Valgus and Varus Rearfoot Wedging on Peak Hallux Dorsiflexion During Gait J Am Podiatr Med Assoc 2004 94: 558-564.)

    In terms of treatment options, I would not base my intervention solely upon the RoM of this (or for that matter any) joint. Much bigger picture is needed!

    Dr O'brien was good enough to supply me with a couple many years ago when we were researching 1st MTPJ function.
  8. Lee

    Lee Active Member

    Thanks for clearing that up. How do you assess for these? I presume like anyone, you manipulate the joint non-weightbearing looking for any obvious restriction of motion. I doubt that subtle alterations detected in these non-weightbearing examinations correlate well with dynamic function.

    Cheers Simon. I've read your paper and Halstead and Redmond's paper on the Hubscher manouvre, which go some way to sparking my interest in the correlation between the variety of clinical examinations, their interpretation and the subsequent effect on the patient's treatment. I've also experienced lower maximum dorsiflexion of the proximal phalanx of the toe relative to the first metatarsal measured using retroreflective marker triads and qualysis during gait than 65 degrees, and it mystifies me as to why we still get 65 degrees thrown about as being the magic number.

    Yeah, I think I mentioned that before, but that's why I made my initial question more specifically about the types of examinations people perform. I'm just interested in finding out about any more that I'm not aware of. You hear about certain examinations of joint function from time to time across disciplines and it'd be nice to see if these have a bearing on how the joint really works and how they can contribute to treatment decisions.

    As an aside, and also as an update, I couldn't get the EMG of abductor hallucis to work consistently (we posted about this previously) - kept moving about, no matter what fancy electrodes I tried. Needle and fine wire were mentioned, but no takers. Oh well.

  9. Lee

    Lee Active Member

    Cheers Scorpio,
    Not heard of this one. Why do you do it, how do you interpret it, and what bearing does it have on your treatment?

    Toe raise - like a tip toe, or do you get the patient to actively dorsiflex their toes whilst standing still? (interestingly, Nawoczenski DA, Baumhauer JF, Umberger BR. (1999) J Bone Joint Surg Am. 81(3):370-6 showed active dorsiflexion to best represent maximum toe dorsiflexion during gait).
  10. Difficult to measure, so difficult to run correlations. I'm usually looking for pain and QOM

    65 seems to have come out of the R,O & W random number generator. Think also about environmental influences. Love also Kilmartin's bone pin paper BTW.

    When Newton was working on optics he used to stick things in his own eyes, maybe this is the way forward. When I was researching more actively I used to try everything on myself, mainly for the laugh but also because there is a fine line between pleasure and pain :dizzy:;) Have fun.
  11. Lee

    Lee Active Member

    They quote an early paper by Joseph in JBJS, I've got it somewhere, but I'm currently re-arranging references.


    Got my scars and permanent radiation burden from in vivo kinematics with intracortical pins already thanks.;)
  12. Forgot to mention I also look for capsular / non capsular patterns- see Cyriax (capsular = restriction of pl flexion > dorsi) compare good with bad side. Also do tip toe rise, looking for direction- picked this up from Craig at PFOLA 2007, so perhaps he'll be good enough to explain the rationale... Me? I'm not sure about this one yet.
  13. Lee

    Lee Active Member

    I'll wait for Craig's reply on the latter, but what's Cyriax? Sounds like a mythical beast that's half man, half shark with skin like an alligator. What's it supposed to show and how does it affect your treatment?
  14. Lee

    Lee Active Member

    Sorry Simon,
    I was being lazy. I've googled Cyriax.
    No mythical creatures.
  15. Supposed to help differentiate pathology within the joint capsule from outside it. Cyriax was an orthopaedic consultant who wrote a couple of books: vol.1 was about assessment and vol.2 was about treatment- he advocated injecting everything with cortisone :wacko:. Vol. 1. is a good read though. Helps identify the tissue being "stressed".

    He looked a bit Alfred Hitchcock, which is cool

    Kilmartins bone pin study here: http://www.japmaonline.org/cgi/content/abstract/81/8/414

    Having slagged the 65, seems Kilmartin's mean of 62 ain't a million miles away (R,O,W where geniuses and I won't hear a bad word spoken about 'em ;)). Been too long since I looked at all this stuff- got a folder somewhere with a stack of papers including Joseph's- might be in the garage soaking up oil from my '77 camper.

    Don't let Nester stick pins in you, send my love and hold your chin as you do it (he seems to get pleasure from this). EMG won't hurt big boy- pay my expenses and you can do it on me.

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