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Any rationale for varus FF type post distal to 1st MP?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by vbt, Nov 1, 2010.

  1. vbt

    vbt Welcome New Poster


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    In our clinic a fellow PT has twice inserted a 2 degree varus post under the hallux, distal to the 1st MP joint, in addition to a 2 degree standard varus post under the forefoot just proximal to the MP joint. This was done with Vasyli devices, for symptomatic functional flat feet. Personally I cannot think of any rationale for the post under the hallux, and it seems as though it would contribute to hallux valgus. Am I correct in my thinking? Thanks.
     
  2. Depends on the patient. I routinely use forefoot varus extensions with runners and especially sprinters. If its just under the hallux, it's basically like a Morton's extension- like I said, depends on the patient.
     
  3. Bruce Williams

    Bruce Williams Well-Known Member

    I agree with Simon that it often "Depends on the patient."

    I disagree that if the post is under the hallux that it is essentially a morton's extension. That would be true only if it was under the mpj and hallux.

    If the post is only under the hallux then it is much more like a Cluffy wedge or digital wedge that works very well for patients with functional hallux limitus.

    Talk with the PT to find out the rationale and explain yours as well.

    Cheers
    Bruce
     
    Last edited by a moderator: Nov 1, 2010
  4. Yep, agree. I assumed it was running from the shell distally but on re-reading the original post you may be right, Bruce.
     
  5. Graham

    Graham RIP

    Slam it and jam it! For every 1deg of dorsal lift of the first mtpj there is 4deg of loss of extension of the hallux! read it somewhere but will have to look for the ref!
     
  6. I hope that ref is related to running, Graham. Like I said horses for courses. I wouldn't necessarily put that into a device designed for walking, in which greater dorsiflexion of the hallux seems to be required due to the double support phase of the gait cycle. However, there are occasions, even in walking, when jamming the 1st MTPJ may be seen as the best solution for that specific patient, at that specific time. We need to know more about the patient.

    I am really interested in that paper though, Graham. In the paper they added dorsal lift to the 1st MTPJ and measured dynamic 1st MTPJ dorsiflexion- right?

    We did a study of forefoot varus versus forefoot valgus wedge effect on step length, when we did a Bonferroni correction http://en.wikipedia.org/wiki/Bonferroni_correction on the data, there were no statistically significant differences. So, step length was not influenced by forefoot wedging, if forefoot wedging influences 1st MTPJ dorsiflexion, then any change that may have occurred in 1st MTPJ dorsiflexion in association with 3.5 degree forefoot wedging doesn't appear to alter step length.
     
  7. Graham

    Graham RIP

    they did! I'll hunt it out for you!

    I doubt that! :drinks
     
  8. vbt

    vbt Welcome New Poster

    Sorry, I should have been more clear. Under the hallux is a 2 degree varus wedge, a square piece of foam that is typically used under the 1st met head for a FF varus post. The two wedges (one under the gt. toe, the other under the distal 1st metatarsal) allow for MP flexion, since they are 2 separate pieces. Both wedges are positioned with the thicker edge palced medially. It is not placed like a Cuffy wedge, where the thicker edge is under the distal aspect of the great toe.

    The patient has significant pes planus and calcaneal eversion standing, and just underwent surgery for an accessory navicular.
     
    Last edited by a moderator: Nov 1, 2010
  9. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    How can padding under the first met/hallux help a pronated foot?

    Easy, first it has to dorsiflex the first ray to end range of motion, then maximally supinate the midtarsal joint to end range of motion, then it can finally have an affect at the subtalar joint! :dizzy::dizzy:

    Unless it trying to act via prof rhubarb's ficitious proprioceptive pathway :pigs: :pigs:
     
  10. pgcarter

    pgcarter Well-Known Member

    If you have some varus presentation of the foot when in STJ neutral and the subsequent compensatory collapse of the medial side of the foot to the floor causes symptoms related to internal rotation of lower leg(and STJ pronation) and femur then putting a medial wedge in under 1st MPJ and hallux is like Root's "bringing the floor up to the foot" and should help decrease the amount of medial collapse and internal rotation???? or wouldn't it??? And if the whole foot is in varus then wedging the 1st is perhaps not dorsiflexing it above the plane of the other four met heads, but just helping them sit in a better relationship??
    regards Phill Carter
    regards Phill Carter
     
  11. Bruce Williams

    Bruce Williams Well-Known Member

    I would do this only in a patient with a fixed dorsiflexed 1st Ray. I'd use a soft poron or ppt wedge for part of the post in contact with the foot as well and consider decreasing it over time. It is a rare condition but not unique.
    Cheers
    Bruce
     
  12. Tell that to these girls and guys:
    Baumhauer J, Nawoczenski D, Patel A, et al. Dynamic assessment of the Morton’s extension carbon footplate on pain, function and plantar loading patterns in patients with hallux rigidus. Presented at the 2010 American Orthopaedic Foot and Ankle Society Summer Meeting. July 7-10. National Harbor, Md.

    http://www.orthosupersite.com/view.aspx?rid=75853
     
  13. Graham

    Graham RIP

    No disagreement there - but these are hallux rigidus subjects not ones with a functional ROm at the MTPJ. Also, a morton's ext is not a varus wedge!
     
  14. Yep, and I'd previously said: "However, there are occasions, even in walking, when jamming the 1st MTPJ may be seen as the best solution for that specific patient, at that specific time. We need to know more about the patient." to which you replied:

    "I doubt it".

    And it is these hallux rigidus patients in which jamming the 1st ray may be beneficial.
     
  15. Graham

    Graham RIP

    Y
    Agreed!
     
  16. Bruce Williams

    Bruce Williams Well-Known Member

    Thanks for posting that link. Interesting results. I'd like to see both video and in-shoe F/T cuves on those people for comparison, as pressure profile comparisons are very subjective and rarely tell the whole story.
    Still, in chronic pain patients with arthritis a win is a win.
    Cheers
    Bruce
     
  17. Bruce Williams

    Bruce Williams Well-Known Member

    Simon;
    I looked at what you wrote above and have to say that from what the study did I don't think they "Jammed the 1st ray". If indeed there is 4 degrees of flexibility and ROM as they stated then they just probably slowed the transition significantly.
    I will admit that I would not usually consider graphite morton's extension as motion enablers, but in this situation it did seem to do just that.
    Bruce
     
  18. Bruce, it all depends on the full range of motion (ROM). If the ROM in these patients pre-treatment is 60 degrees then reducing it by 4 degrees is only a 6.6% change, if the ROM is 8 degrees pre-treatment then reducing it by 4 degrees is a 50% change. What we don't know from the link is what the observed ROM's were without the Mortons extension in place, but we do know they had "hallux rigidus". How many degrees of 1st MTPJ dorsiflexion do you consider as hallux rigidus as oppose to limitus?

    My concern is that we don't know the between day error in the 1st MTP dorsiflexion measures, or very much about the methodology from this link. 4 degrees is small, and the between day error might be 4 degrees or more.:bash:

    Not sure how you get to "motion enablers" though, when they reduced the dorsiflexion?
     
  19. Bruce Williams

    Bruce Williams Well-Known Member

    My point is just that there does still appear to be motion due to flexion of the morton's extension. Your point on margin of error is true and therefore there could be total blockage of motion.

    I don't disagree that in certain cases such as this that the best treatment may be the stoppage of motion of a painful joint. Sometimes you can't beat it any other way.

    no worries, good discussion.
    Bruce
     
  20. Cheers.
     
  21. pgcarter

    pgcarter Well-Known Member

    The original paper looking at dorsiflexion of the 1st met and resultant loss of dorsiflexion ROM of the hallux was Green and co I think? is this the one you are referring to?
    regards Phill Carter
     
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