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Digital Amputation and Orthoses

Discussion in 'Biomechanics, Sports and Foot orthoses' started by lcp, Mar 5, 2008.

  1. lcp

    lcp Active Member

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    Gday all, I am currently treating a patient for plantarfasciitis and post shin splints but have come across a bit of a concern. The patient has had the majority of his right hallux and all of his 2nd digit removed as a result of severe frostbite following a climb of Mt Everest in 2006. He is what I would class as extremely active, running 12k a day, rock climbing, hiking, mountaineering, and being active is his highest priority. However, I have never encountered a patient this active with digital amputation before. Could any of you enlighten me on any orthosis modifications/additions that may cause further problems with this situation, or anything you may suggest to be beneficial for him.
  2. Craig Payne

    Craig Payne Moderator

    Has the windlass been interfered with as result of partial hallux amputation?
  3. lcp

    lcp Active Member

    yes mate it has
  4. Craig Payne

    Craig Payne Moderator

    Refer him to an enemy :dizzy:
  5. lcp

    lcp Active Member

    haha thanks for the advice mate.
  6. Cameron

    Cameron Well-Known Member


    Depends how much of the hallux remains. If there is sufficent proximal phalanx to act as a stopper then a silicone prostheses for the second toe can simply be made as a three two prop. Crude, but will fill the gap and contribute to whatever remains of the windlass action through a platform of the three middle toes. I have found this technique (alone) can help in the symptoms associated with extended pronation into propulsion (e.g. shin splits). This approach may be successfully combined with orthotic rearfoot management.

    When sufficient hallux is missing this approach presents technical problems but can be overcome with a combined dorsal and plantar prop (adhered with silicone glue).

    More ornate silicone cosmeses are possible and prosthetic hallux and second can be added to a forefoot cuff. The technique was developed in the 70s by Jim Black in Glasgow. This is cosmetically appealing which has a psychological advantage but the disadvantage is the cuff is privy to turning moments on the forefoot which may cause it to swivle. Not perhaps the best thing when climbing.

    A commercial product that might help is Vibram® FiveFingers®. Vibram® FiveFingers®, were developed for sailing, climbing and light trekking. The foot like sneaker for extreme sport has a rubber sole contoured to the shape of the foot and a separate pocket for every toe (ie easy to fill with a prosthesis).

    Have a swizz:


    The idea we need the hallux to be active is rather a myth as this client clearly shows. Why we have five digits per extremity is we can afford to loose one or two without too much disadvantage. Having all ten is definately the way to go. I might suggest his symptoms are more to do with over exercise and getting him to accept exercising to tollerance which might benefit him in both in the short and long run (no pun intended).

    Good fortune
  7. Jeff Root

    Jeff Root Well-Known Member

    You may want to try inverting his right orthosis perhaps five or six degrees (intincically or extrinsically) to help him compensate for the decreased windlass mechanism. Since the partial loss of his hallux has resulted in a shortened lever arm for resupination, then inverting his device may help him by increasing the supination moment in the forefoot. Other considerations are toe filler, Morton's extension depending on residual length of hallux, or a varus extension added to the top cover of his orthosis. With any orthotic intervention, have the patient watch for signs of irritation at the residual hallux and use a conservative break-in. These modifications would be in addition to good proximal support (ie. good arch contour and contact, high medial heel cup, extrinsic rearfoot posting, etc.).
  8. lcp

    lcp Active Member

    thanks for the replies, he is definitely a unique case for my clinic. whichever way i go will be a learning experience nonetheless. unfortunately, moderating exercise is not an option for this patient, he would be THE most active patient i have ever seen, and wants to stay that way hence the visit. i should have mentioned also, the running he does is purely trail running, no flat road or treadmill, and if any of you have seen the kangaroo valley region of nsw, trails are by no means a casual jog through the bush, very very rugged. ill have to factor this in regardless of what i do, as i reckon he wouldnt be impressed if i increased the risk of greater injury!!
  9. pgcarter

    pgcarter Well-Known Member

    I dealt with an individual who lost most of his digits in a press accident, they were amputated by the steel toe cap when it came down on the foot. he still has the met heads and plantarfascia appears attatched at the distal end but I'm not sure to what. He had on going contracture/tightening problems over a period of years. Have not seen him for a while. I made him a variety of things to try, including a shell with hallux extension, shell stopping at met heads, and EVA devices......which he ended up being more comfortable in later, but was better in a torsionally rigid shell to begin with.
    regards Phill
  10. Paul:

    I don't know if I can totally agree with any of the suggestions offered in this case so far. In patients like these, Paul, the first thing that I do is take a good history. Is he in any way bothered by his hallux or 2nd digit amputation sites? Since you do not mention it in your note, then I assume he has no hallux of 2nd digit stump pain or symptoms.

    Now, if there are no hallux or 2nd digit stump symptoms then I would ignore initially in my treatment plan that he ever had these digital injuries and then proceed to take care of his plantar fasciitis and medial tibial stress syndrome (MTSS) the same way I would if he had all his toes. For plantar fasciitis and MTSS (which I assume is on his right side) in a runner, a full length inverted orthosis helps and specifically for MTSS, a varus forefoot wedge to the sulcus added to the orthosis may be critical in getting the patient less symptomatic during running.

    In runners, the windlass effect is not that important and in addition, since the patient doesn't have much of a hallux, then the windlass wouldn't work normally anyway. The bottom line is if this guy can run, rock climb and mountaineer, and has climbed Mt. Everest, he is already doing more activity than 95+% of the population without his hallux and 2nd digit so that losing a few digits certainly isn't going to slow him down. What this patient does need from you, Paul, is for you to concentrate on what he needs (i.e. to be less painful with running) so he can continue to do what he likes best.....being very active in the outdoors. Forget about the missing toes and treat him like you would treat any other runner with plantar fasciitis and MTSS, then adjust the orthosis as necessary to relieve any irritation to the digital stumps, if this occurs at all.

    I understand completely your patient's personality and desires...I was a crazy athlete in my earlier days (70 - 100 miles of running per week from the ages of 16-24) and would never have let a few missing toes get in my way of training and competing if I had any other choice in the matter.
  11. lcp

    lcp Active Member

    thanks kevin, that is pretty much what I was getting at, whether or not any specific orthotic modifications would cause problems with the lack of digits. As he is not getting any problems with the halux or 2nd area, I didnt want to cause any myself. I ended up going with basically what you desribed above for that reason, treat the condition he presented with, and help him with the problem he desribed when I asked him what I could do for him. Apart from his intense exercise, his career involves pushing others to their limits in training/development/motivation exercises in the outdoors, so it was pretty important for him to be at his peak. Not very motivational when your instuctor/leader is 200m behind you yelling at you to wait up!! Thankyou all for your help and advice, its good to have this option for us available.

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