Hello,
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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) ?
Cheers,
Lee
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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?
Lee -
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.
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.
Lee -
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 -
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!
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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.
Lee -
Not heard of this one. Why do you do it, how do you interpret it, and what bearing does it have on your treatment?
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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.
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Simon,
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?
Lee -
Sorry Simon,
I was being lazy. I've googled Cyriax.
No mythical creatures.
Yet. -
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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