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1st MTPJ OA in 14yr old

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Walsh, Jul 31, 2010.

  1. Walsh

    Walsh Member

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    Hello I would like to ask for some help / discussion regarding a patient who is just 14yrs old and has a history of R/knee pain which I succsefully treated when he was 12 with an orthotic. The knee pain was pattella ligament disfunction caused by excessive pronation.

    Having seen him recently he presents with pain in his right first MTPJ aand on examination shows reduced motion in the joint with 65 degrees dorsiflexion and shows osteophytic lipping.

    He is a keen footballer and has a history of about a year ago having a traumatic incident to the joint durting playing football. (This I thought may have accelerated the condition.)

    His gait shows excessive pronation on both feet but the right has an abductory twist motion just after heel off. He has a more external hip posityion on the left side which would appear to be causing this but this position going into propulsion obviously isnt helpful as it is casuing the dorsiflexion of the 1st ray and associated FHL problems.

    My problem is in trying to treat him. He also has some anterior cavus. To try to fit anything in a football boot is extremely difficult. I am trying to promote 1st ray plantarflexion by giving a kinetic wedge and trying to control the rearfoot as much as possible, however the problem mainly occurs when his heel is off the ground going into propulsion so I am puzzled as to the best way to help this condition and get the plantarflexion of the first ray in propulsion as the foot is abducting and pronating going into that phase as the heel come off.

    Any thoughts would be appreciated.

    Thank you.
  2. Brandon Maggen

    Brandon Maggen Active Member

    Hi Walsh

    This is a difficult case as the correction of the rear foot and the kinetic wedge are al standard and viable options in this case. However if the abductory twist at heel lift and into propulsion is the problem as you see it on gait and clinical examination, then you need to get the help of a Chiropractor/Osteopath to help with the hip and pelvis adjustments. Also, of help may be to adjust his fibula head anteriorly. A rocker-bottom heel adjustment on his boots may also be of benefit as it will delay the heel lift.
    Good luck
  3. Walsh

    Walsh Member

    Thanks for the help. Your right this is a difficult case. I would like to ask if the rocker bottom is fitted to an insole or the shoe. And how it is done. Can it be done simply or do they need to be sent to a lab. ?
  4. Hi 1st I´m a little confused what are you trying to treat ? The knee or the 1st MTP joint or both ?

    If pain is caused on dorsiflexion of the 1st MTP why are you using a Kinetic wedge ? It must be adding to the compression forces at the 1st MTP joint.

    He maybe a patient who required 2 types of devices. 1 for his football boots and another for everyday wear.

    The football device, good rearfoot control and FF varus post - forget windlass, reduce the 1st MTP dorsiflexion, invert the whole foot, which will help with frontal plan knee mechanics. Will also take up less room in the boot. You may have to encourage balance training to increase the strength of the lateral ankle ligaments.
  5. Walsh

    Walsh Member

    Thanks for that. I should have said that the knee pain is no longer an issue the only problem now is the osteophytic Lipping in the right first MTPJ. The pain is caused by dorsiflexion of the hallux. Functional hallux limitis is the main reason for this I feel which is happening due to probation of the rearfoot and abductory forces from the hip causing the abducted forefoot position at propulsion. Which is when the doriflexion of the 1st met is occurring. The kinetic wedge as far as I understand it is designed to allow the 1st met to plantarflex and thus promoting normal 1st ray movement.

    It seems hard to treat because when trying to prevent pronation I need to lift the heel and invert the foot but at heel off there is a massive pull into abdcution by the hip presenting the foot at a poor position for propulsion.

    It is interesting you said to forget the windlass effe t and just control throughout. I have not tried that approach but I am worried that if I dorsiflex the 1st met I may bring on the 1st MTPJ OA quicker.
  6. Griff

    Griff Moderator


    I'm a bit confused

    On examination he shows reduced motion - so a structural hallux limitus? (65 degrees of dorsiflexion doesn't sound like reduced motion??)

    So is this a functional or a structural problem in your opinion?

    If a kinetic wedge allows a first metatarsal to plantarflex, then this would generally promote a dorsiflexion moment of the 1st MTPJ/hallux. And you have said that hallux dorsiflexion causes pain? If dorsiflexion = pain and your aim to to reduce pain, then then any intervention should surely aim to not dorsiflex the hallux? How do you think you could achieve this? Would it be appropriate to do this?

    Have you a recent X-ray of this young chap?
  7. Walsh

    Walsh Member

    Sorry about being vague.

    Range of motion of the first MTPJ shows just 65degrees dorsiflexion of the hallux, but with some pain at the end of this motion. I realise this isnt true hallux limitus but he does have some osteophytic lipping and it has reduced from 90 degrees of motion just 2 years previously when I saw him. As I said he had a traumatic incident which may have led to accelerating this condition but his gait does suggest to me functional hallux limitus at propulsion. I feel that the functional hallux limitus is causing the hallux to impinge the first met and cause the osteophytic lipping and leading to reducing the actual range of motion in the joint over time.

    This functional hallux limitus is causing some pain after exercise but again I feel it is due to the pronation and corresponding dorsiflexion of the first met on a dorsiflexed 1st met because of pronation and foot position at propulsion and the hallux impinging on the first met.

    My theory was that if I can get the 1st met to plantarflex and the hallux to dorsiflex at propulsion (after all the actual range of motion is there - just not being used), then I may be able to get better propulsion and less pain.
  8. So the kid is now 14 when you last measured he was 12, in the classic measurement of limited range of motion of the 1st it´s 65-75 degrees of motion. But in realitiy it a terrible measurment, what we should be looking at ( and I now do thanks to Bruce Williams) is dorsiflexion stiffness, ie the amount of force required to dorsiflex the 1st MTP joint.

    The Dorsal lipping or any other Osteoarthritic changes of the 1st MTP joint would put the reduced Range of Motion of the 1st into the structural area, but we can have both.

    ie Structural Hallux limitus and increased Dorsiflexion stiffness of the 1st.

    How does a FnHL cause pain and where does in cause the pain, you have stated that the pain is in the 1st MTP joint. A FnHL limitus is an increased in dorsiflexion stiffness of the 1st MTP joint, which is caused by tightness in the plantar intrinsics and plantar fascia. ( there is a huge debate about if the FnHL is the chicken or the egg, which we can leave alone at this stage).

    A FnHL will change the length of the lever arm of the foot, which will mean some gait changes but often the area of tissue stress are in other places, such as the triceps surea, but in this case the patient is in pain in the 1st MTP on dorsiflexion.

    As a said in my 1st post when you were discussing the kinetic wedge why would you use this if the pain occurs from dorsiflexing the1st MTP joint.

    take this dumb example - a patient says to you I get pain in my leg when I stab myself with this knife - the 1st thing you would say is stop stabbing yourself with the knife....

    so if the 1st MTP jointis painful when you dorsiflex the toe, reduce the amount of dorsiflexion of the 1st MTP joint, not increase it.

    again how would better propulsion lead to less pain in this patient ?

    Stuff to consider, hope it helps
  9. Walsh

    Walsh Member

    Thanks for the reply.

    I have heard of measuring hallux dorsiflexion stiffnes before but not done it, is there a paper about it? and is there a measruing device?

    My thoughts on why he was getting the pain is that this is occuring because of the FnHL and if he could be made to propel more efficiently then this might not happen.

    Yes I agree that if it hurts to dorsiflex then dont do it, but to stop the 1st MTPJ from dorsiflexing seems the wrong thing due to not allowing correct function within the foot. I thought by promoting the dorsiflexion in a proper way not a FnHL way this would reduce the pain he was getting.

    If the windlass is working correctly the hallux should move over the anterior dorsal surface fo the 1st met with no problem but obviously not in the FNHL state where the bones jam.

    I thought as long as he has upto 65 degrees motion then I can restore foot function to 'normal' and thus help his pain. Stopping the hallux dorsiflexion may yes get him out of pain but am I setting up other problems for the future, and can I get him out of pain by promoting the 'normal' propulsion mechanism by supporting his foot and trying to allow 1st ray plantarflexion and the efficient dorsiflexion of the joint?

    Thanks again.
  10. It all about force which will be different for different activities.

    You have said the pain is from dorsiflexion of the 1st, a FnHL will often mean that the amount of dorsiflexion is less, due to the inability of the body to over come the plantarflexion moments on the 1st. So in many ways the functional hallux limitus or increased dorsiflexion stiffness will reduce the compression forces on the dorsal aspect of the 1st MTP joint ( the structural hallux limitus, or dosal lipping you mention) ie is may be a help to reduce the pain.

    I a bit confused by this statement, can you expand on it ? Functional and structural are different things.

    Think tissue stress, in this case you can´t have more than a certain amount of dorsiflexion of the 1st MTP without pain, deal with the symptoms.

    If in the future he requires a little clean up surg on the dorsal limping you may have helped reduced the amount of boney development thru reducing the compression forces on the doral surface of the 1st MTP, which may mean better post-op results. You have stated that trauma was mentioned by the patient.
  11. Walsh

    Walsh Member

    The main issues I can see is are that he has slight OA of the joint and at end of ROM this causes pain. He suffers with pain after exercise and his gait shows he has an abductory twist on the right side as he goes into propulsion, He has a pseudo equinous and is pronating as well. My thoughts on why he gets this pain are due to FnHL due to the over pronation but you are corerct in that I am assuming FnHL would hurt. Other than that I am not sure why he would get the pain.

    Good discussion, making me think, thanks!
  12. efuller

    efuller MVP

    There's not enough info to decide whether or not to use a kinetic wedge (reverse Morton's extension) or not. It might be very hard to get that information clinically. A functional hallux limitus will hurt because of increased compression forces in the joint. This may hurt at maximum dorsiflexion or in the middle of the range of motion when dorsiflexion is attempted. On the other hand an injury to the dorsal 1st met head will hurt when the 1st mpj is dorsiflexed enough for the proximal phalanx to hit the injured part of the joint. In this situation the reverse Morton's would be wrong and a stiff shoe would be right.

    If the problem is a functional hallux limitus then using a reverse Morton's extension will reduce the compressive forces in the joint. You could try it and see if it works. Perhaps you could even tell the patient that "this might make it feel better, but there is a small chance that it will feel worse and in that case it should be removed.

  13. drsarbes

    drsarbes Well-Known Member

    Reading through these posts......I'm still not clear whether this is a post traumatic arthritis of the 1st MTPJ or is it an early hallux limitus due to pathomechanics?
    Is this unilateral?
    What do the xrays show?
    Is the first ray long?

  14. Griff

    Griff Moderator


    I'm not sure Dean knows either. I asked about X-Rays in post #6 and never got an answer
  15. drsarbes

    drsarbes Well-Known Member


    This reinforces what I've said here many times before. A successful treatment begins with an accurate diagnosis.

    I just don't get how one can keep trying various treatments until, perhaps, one renders some relief then makes a diagnosis in Retrospect.

    This is how it's done in Bizarro World.

  16. Walsh

    Walsh Member

    No unfortunately I dont have X-rays to see. I only have the clinical findings, which show no creptius but what appears to be an osteophytic lipping and reduced ROM in the joint (just 65degrees).

    The pain seems to have improved with treatment for antipronation and kinetic wegde at the moment and he has been able to play football without symptoms which I have been pleased with.

    My feeling is that it is mainly the FNHL Causing the problem and thus reducing this issue it has helped. I feel post traumatic injury has caused some actual reduction in the joint ROM but the the pronation has added together to accelerate the issue he has been getting.

    I will continue to treat in this mannor and hopefully his symptoms will stay away, I would normally go for trying to keep the joint moving in gait until such a time that the ROM is less than 65degrees and then go for shaft pads etc and stiff soles etc to reduced ROM of the joint.

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