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Functional Hallux Limitus- Treatment options

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Holapod, Jun 26, 2017.

  1. Holapod

    Holapod Member


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    Hi All, I have had two patients present recently with functional hallux limits both with different foot structures and presentations. I'd appreciate any advice on management via 1st ray cutout or cluffy wedge

    -28 yo amateur AFL player 6'4 100kg generally supinated foot type. Tight gastrocs+soleus and hamstrings. Functional hallux limits. history of 6-8 weeks of 1st MPJ pain no hx of trauma. unable to elicit pain but demonstrated pain occurs on toe off. Has been having strapping of 1st MPJ which has been assisting pain.
    I am suspecting 1st MPJ capsule strain but noted that he had very little to no hallux dorsiflexion with Jacks Test. He is generally pain free when just walking around

    I am wondering if I should be looking more into an orthotic with a morons extension to treat the capsule strain or considering a cluffy wedge/1st MPJ cutout. Im concerned any type of loading onto the hallux will further exacerbate the issue.

    The second patient is a 32yo slim female. R foot hallux limits which she is experiencing mild 1st MPJ pain and mild heel pain. Severly pronated through the rear foot with a non-wb forefoot varus and high supination resistance. When I place the rear foot into a more neutral position the 1st ray is unable to reach the ground and the patient says it feels uncomfortable. Should I be looking at managing with a cluffy wedge and if so whats peoples experience with these?? any tips?

    thanks
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. efuller

    efuller MVP

    You should assess STJ axis location in the transverse plane. This can help you understand the cause of pronation Often people with a "supinated" foot type will have a laterally deviated STJ axis. Often these feet will exhibit late stance phase pronation. My theory is that this pronation is caused by muscular peroneal muscle activiation in response to the ground tending to cause a supination moment at the STJ. In this kind of foot attempting to pronate the STJ can be helpful. This foot will tend to pronate and lift the lateral column off of the ground relatively early in stance phase (compared to those with a medially deviated STJ axis) this will cause high loads on medial column causing the functional limitus. \

    You did say that it was a functional limitus, but you did not say how much NWB range of motion of first mpj there was. Agree with strapping. You may be able to reproduce first mpj pain by compressing the toe into the metatarsal while attempting ROM of the MPJ.

    If there is normal motion of the MPJ, do not use a Morton's extension. Use a reverse Morton's extension.


    The foot with muscle caused pronatoin is different from the with ground caused pronation, but they both can have functional hallux limitus.

    This sounds more like a foot with a medially deviated STJ axis. (high supination resistance). In both of these foot types a high pronation moment from some source (ground or muscle) will tend to make the windlass work in reverse to prevent hallux dorsiflexion in gait. In the medially deviated STJ axis foot, and not the "over supinated" foot, you really need to increase supination moment (medial heel skive or varus wedge) with your treatment. Both can benefit from a reverse Morton's extension. You could do a cluffy wedge with the reverse Morton's. extension.

    Even though you measured a forefoot varus, I would tend not to add a forefoot varus wedge or a forefoot varus intrinsic post in the orthotic for this complaint.


    Eric
     
  4. Holapod

    Holapod Member

    Hi
    Hi Eric, thank you so much for your response. I have been doing some reading on STJ axis and agree that I need to update my knowledge on the assessment and theory behind this. With my second patient-medially deviated STJ when I put a supination moment across the rear foot the patient complains that they feel that the forefoot and particularly 1st MPJ is off the ground so I am concerned about a reverse mortons exacerbating this issue. Is this something that is just adjusted to over time?

    With the functional hallux limits range of motion was "normal" in NWB then significantly reduced in standing when trying to do a jacks test. Also significantly reduced in NWB when I loaded the 1st ray and reattempted dorsiflexion
     
  5. efuller

    efuller MVP

    Have you read Kevin Kirby's papers on palpation of the location of the STJ axis, and rotational equilibrium? Kevin and I wrote a chapter for a book where we distilled our ideas into one place. I don't think we went into as much detail on finding the location of the axis as there is in Kevin's paper.

    There is a difference between a supination moment and a supination motion. You can add supination moment without actually causing supination. It is quite difficult to significantly change the position of the STJ with an orthosis. Try to supinate the foot with your orthosis without lifting the first met off of the ground.

    The only problem I"ve had with a reverse Morton's is when I've added it when there is a foot with a relatively long 2nd met. When there is a long 2nd met, I will tend to add a valgus wedge, rather than a reverse morton's. This assumes that there is eversion range of motion available in stance.


    Most of the time, in the laterally deviated STJ axis foot, the Jack's test is quite easy and you will see supination. The exception occurs when the axis is so far lateral that the peroneal muscles are firmly contracting in "relaxed" stance. This occurs because when the peroneals don't contract the foot would roll into inversion. In these feet you can see, or palpate, the contracting peroneal muscles and see a difficult Jack's test.

    The laterally deviated axis foot does well with valgus forefoot and rearfoot wedging or orthotic modifications.

    Eric
     
  6. Holapod

    Holapod Member

    Thanks again Eric great info. Yes I have 2 of Kevin's books that were collection of articles that were great. It's been a few years since I read them so rime to relook over them I think.
     
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