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Effectiveness of Vayli Danenbergs for hallux rigidus

Discussion in 'Biomechanics, Sports and Foot orthoses' started by rachel.liminton, Nov 5, 2011.

  1. rachel.liminton

    rachel.liminton Active Member

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    I am currently treating a lady with FHL in her right foot and SHL in her left foot and wondering whether Danenberg orthotics would be appropriate. My concern is that there would not be enough rigidity in the insole to fully support the foot with the SHL...any advice gratefully appreciated. :bash::deadhorse:
    Last edited: Nov 5, 2011
  2. Hi Rachel

    your title says Hallux Rigidus - which is no movement of the 1st MTPJ dorsiflexion or plantarflexion.

    FHL - limited dorsiflexion of the hallux on weightbearing due to an increase in plantarflexion moments acting on the joint.

    SHL - structural Hallux limitus - due to changes in the joint which reduce dorsiflexion ROM ie Increased bone on bone compression which occurs from Osteoarthritis.

    bit confused but

    A Dannenberg device from Vasyli will hopefully reduce the plantarflexion moments acting on the 1st MTPJ- which will allow greater dorsiflexion if the ROM is available - this would be a bad thing for the joint which has a structural Hallux limitus as there is more likely to be an increase of bone on bone compression forces and therefore the possibility of pain or increased pain.

    what you would want to do is increase the plantarflexion moments or increase the dorsiflexion stiffness ie a mortons extension with this structure hallux limitus if the patient is in pain
  3. Craig Payne

    Craig Payne Moderator

    They are not effective for hallux rigidus and may even be dangerous!
  4. rachel.liminton

    rachel.liminton Active Member

    Thank you for your advice. Any suggestions for prefab orthotics with inbuilt mortons extension available in the UK? :eek::eek:
  5. Got some EVA glue and a grinder ? make your own

    or a full length prefab with no Forefoot posting cut away the Forefoot extension leaving a mortons extension
  6. Griff

    Griff Moderator

    There's not one that I'm aware of.

    What is the pathology you are treating? (i.e. What are the patients symptoms and what is the diagnosis?)
  7. rachel.liminton

    rachel.liminton Active Member

    OK, from the beginning...my lady presented with painful left 1st MTPJ and some discomfort from time to time in her right 1st MTPJ. Upon examination she appeared to have FHL to her right, but extensive arthritic changes to her left 1st MTPJ resulting in hallux rigidus.......What I'm trying to do is find a pair of orthotics I can modify to achieve optimum function for her right foot and stabilize and support the left foot.....I have discussed with her rocker bottom shoes etc... but she would like a pair of insoles to use in her golf shoes. I don't have extensive equipment to create my own orthotics to the standard i would wish to sell on and was kind of wondering what was off the shelf that i could modify to accommodate her needs......:dizzy::confused:
    Last edited: Nov 6, 2011
  8. Rachel:

    If you were an auto mechanic, would you try to open up a auto repair business without the proper tools and materials so you could properly repair cars? I hope not. Your customers wouldn't be too impressed with you if, for every car repair, you told them that you will need to go borrow or buy the proper tools and materials before you could properly fix their car.

    In much the same way, the podiatrist who wants to provide their patients with proper custom foot orthosis therapy (modifying pre-made insoles or custom orthoses) will need some basic tools and materials in order to provide their patients with the most basic orthosis modifications. In that way you will be more efficient, look more expert and your patients will receive better service and care.

    Here is what you will need to get started. Possibly others in your own country can help you find suppliers for these or equivalent materials.

    1/8" adhesive felt
    1/4" adhesive felt
    1/8" korex (or EVA)
    1/4" korex
    Barge cement
    Barge cement thinner
    Dremel tool with grinding bit
    Bulk Spenco or EVA sheets for insoles
    Bandage scissors

    With these few materials, and the knowledge of how to use them, you could have made a Morton's extension for your patient in about 60 seconds.

    Good luck in your future career.:drinks
  9. rachel.liminton

    rachel.liminton Active Member

    Thank you for your comments....was not expecting the giants of podiatry to respond....some what intimidating.....we all have to start from somewhere....i strive to offer the best service i can provide given the education and experience that I have...if in any doubt as a responsible podiatrist I check out with others....maybe I should retire..even though i have barely begun:craig::sinking:
  10. Rachel I would take this as a positive learning experience - now that you are out it is up to you to gain experience - some of this your education should have given you however Podiatry education has changed a lot since I left School.

    But now that you are out you need to seek further education - a mentor, Podiatry Arena and conferences etc.

    It is great that you asked the question and hopefully you learnt something and some of the dismay you may feel perhaps should be directed at the School you attended, but don´t look back work hard gain knowledge go forth and concur. :D
  11. blinda

    blinda MVP

    Hi Rachel,

    I can identify with your response. It IS an absolute privilege to have the more experienced/influential podiatrists offer us free and practical advice. You have taken the bold step of requesting help, something many `lurkers` only dream of doing. Can I offer you some advice? Don`t be intimidated or retire, you`re asking the questions that many don`t have the courage to ask. Keep going gal:drinks

    BTW, for work I wear a VHD with plugs removed on my left (for "FnHL") and a full length dual density ICB on my right (with a forefoot 2-5 cutout, my modified Mortons` extension, for my increasingly painful dorsal osteophyte; ie read, SHL).

    Hope that helps!

  12. Rachel:

    No worries. I was once a young podiatrist (about the time they invented wheels) and I occasionally had to be beat up on the side of my head by my professors so that I was guided in the proper direction. We call that learning. I'm sure, in not so many years, you will be able to return the favor of providing useful advice and education to some young podiatrist who is searching for answers also.

    "Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning." Albert Einstein

  13. Rachel,

    In answer to your original post, I'd use some felt stuck onto a full length prefab insole to test a Morton's extension. I've used kinetic wedge modifications with success in structural hallux limitus- so the Dananberg device might help. Finally, I'm just up the road in Plymouth, I take biomechanics referrals from podiatrists throughout the South-west for any of those patients you may be struggling with. I'm happy to offer advice over the phone, whenever you "get stuck".

    01752 241442
  14. It was before then, surely? Fire? Perhaps not, the cassette maybe? I just purchased Grandmaster flash and the furious five on cassette from a boot sale, couldn't resist- sounds awesome. Pain in the arse for track selection though- fast forward to "the message"....

    (I also procured a pair of Farah hop-sacks to split over my G. Villas. Going to be stealing Ian G.'s Pringle jumpers next and go curly perm at the back. Oh, to be 14 again).
  15. rachel.liminton

    rachel.liminton Active Member

    Thank you Kevin....once out of uni there is a lot more learning to do...i know my limitations and ask if necessary...don't want to mess up if at times it seems like basic stuff..and i look a plonker ..i do lots of routine podiatry and not very often presented with biomech problems so not my strongest point....i'm sure i deserve a good beating from time to time....thanks for your support..;)
  16. Good man, Dr. Spooner. Pretty soon you too will be known as being "traditional".:drinks
  17. blinda

    blinda MVP

    Anyone who uses the description of "plonker" in podiatry is cool in my book;


    Enjoy the rest of your weekend:drinks
  18. rachel.liminton

    rachel.liminton Active Member

    Thank you Belinda,been a rough afternoon....been bracing myself....but hey it's all a learning curve...just want to do the best for my patients and not get it all wrong....thanx for support.....:drinks
  19. A little hint we all get it wrong sometimes ;) but through education and learning hopefully less often
  20. Hmmm. Maybe one day. I'll let you bask in that one for now, old man ;)
  21. rachel.liminton

    rachel.liminton Active Member

    Simon, Kevin is my guru...you can't say that!!!!!:eek:
  22. OK, I've been wondering whether to post this all day as I did not want to confuse Rachel, but anyway...

    It relates to your post above Mike but probably more so to Craig's...

    You know what I'm going to say Craig.....

    Show me the evidence.

    What do we know regarding the biomechanical effects of kinetic wedges?


    It's pretty much the same as the debate here: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=71007
  23. I think you'll find that I can. He's one of my best mates, co-author on a couple of my papers, and my mentor. Moreover, I got video of him spinning in a tube.
  24. rachel.liminton

    rachel.liminton Active Member

    Sorry Simon ...only jest...interesting about your last post though and kinetic wedges..
  25. The jest was taken in the light it was intended, don't worry (Jeez, do people think I have no sense of humour?:dizzy:)

    Yep, before we can make statements like kinetic wedges could be "dangerous" in hallux rigidus, it might be helpful if we look at the data that we have that has examined the kinematic and kinetic effects of such modifications. Morever, perhaps it is time to examine our own assumptions regarding "normal and abnormal function"?
  26. The only time that I would consider a Morton's extension "dangerous" is if you aspirated it.:rolleyes:
  27. I think one of the problems is that many have accepted the hype and the "picture on the box" as to what Vasyli Dananberg foot orthoses "do", without ever having examined the science as to what it is that they actually do do. Combine that with some unproven theories regarding lower-limb function during the propulsive phase of gait and you get notions from some of the best respected podiatrists in the world like "kinetic wedges are dangerous in hallux rigidus". It's an interesting idea Craig, tell us more...

    As many of you already know, I've always loved marketing and believe without a shadow of a doubt that foot orthoses work just like the picture on the box, y'all know the one....:bash:

    And I'll keep posting it until those in marketing actually take action upon this... http://www.youtube.com/watch?v=gDW_Hj2K0wo
  28. Craig Payne

    Craig Payne Moderator

    I did not exactly say that. I said "may be" ... they have the potential to be harmful in that you can further force a joint with a structurally reduced range of motion to try and move even more --> thats possibly going to hurt.
  29. Mate, I'll give you that you said "maybe harmful", but here's the reality: Do we have any data which demonstrates that kinetic wedges increase dynamic peak hallux dorsiflexion? Do we have any evidence which suggests that an increase in peak hallux dorsiflexion is detrimental to the prognosis of hallux limitus /rigidus?

    I bought the theory and supposition too, but what do we actually know? "It seemed so plausible" http://www.funnyordie.com/videos/2a61aa471c/bill-hicks-it-seemed-so-plausible-from-classicstandupfan

    Something for all to consider: how do foot orthoses work? Kinetics versus kinematics.

  30. Even if the - data which demonstrates that kinetic wedges increase dynamic peak hallux dorsiflexion? if we have Hallux Rigidus the kinetic effect will not be at the 1st MTPJ anyway - Rigid is rigid and therefore the 1st ray will in fact be a longer lever .....

    So as Craig stated for Hallux Rigidus we would be talking about kinetic change at a different joint than a Hallux Limitus structural or functional.
  31. Mike you can have kinetic change at joint without any noticeable change in it's position. So even in hallux rigidus you may alter the kinetics at the 1st mtpj.
  32. How ?if the joint has destructed and fused so there is no movement ie rigid.

    so a MTPJ which has been surgically fused you can alter the kinetics at the 1st MTPJ?

    If we are talking true rigid and 1 degree of movement would not be rigid but a limitus

    I don´t see how you can alter the mechanics of a joint if that joint no longer is there, which is why I believe people with true hallux rigidus are often not in pain at the 1st MTPJ unless from a thickening of the joint and shoe wear related issues . ie the joint no longer is part of foot mechanics, and the 1st ray is now longer.

    see Rachel all learning as I suspect I am about to be learned

    Also without movement there is no axis without axis how do we determine what moment would occur ?

    Maybe my thinking that true Hallux rigidus is a " self " fusion is not correct ?
  33. Peter

    Peter Well-Known Member

    Rachel, sometimes the best success comes from the little things we give to our pts. Initially, you may wish to advise your pt to obtain a quality walking shoe, with a thick inflexible outsole and forefoot rocker/spring to reduce bending moments of the 1st MTPJ. This alone may make her comfortable, if not, she has purchased the necessary shoe with the volume available within to initiate orthotic therapy.
  34. Can I change the bending moment in a bone? You might want to check your definition of kinetics.
  35. Griff

    Griff Moderator

    Mike, it's round about this time I find it helpful to think of fat kids on one end of a see-saw.
  36. Yes of course we can change bending moments in a bone but you were specific and said
    and while bending moments may change at that point where the 1st MTPJ was it still does not change the point I was making which was that

    Perhaps not is a bit strong mostly likely a better way of saying it

    as an aside the point of fusion would have greater stiffness and therefore be able to resist bending moments greater than the rest of the 1st ray.
  37. I have no idea what you are talking about. Yet, I suspect you don't know the difference between kinetics and kinematics.
  38. except this see-saw does not have a fulcrum because the joint is fused - which is why I was suggesting the distal and proximal joints of the now longer 1st ray with Hallux Rigidus would be were the kinetic and kinematics changes would occur by my thinking.
  39. Mike I think you are splitting semantics for the sake of it. The joint still exists in hallux rigidus, i.e. the bits inside the joint capsule. The kinetics can still be altered at the 1st MTPJ even in a hallux rigidus without a change in kinematics, in the same way that the bending moments can be altered along a bone without a joint in it. Much as this splitting hairs is interesting, I really have better things to do with my time.

    Moreover, lets take your contention that we cannot change the kinetics across the area known as the 1st MTPJ in the case of a fusion / hallux rigidus; this being the case how on earth can orthoses be dangerous as Craig contended in this situation? Indeed, Craig maintained that this type of device may be "dangerous" because:
    Anyway off to the vets with Boo! now.
  40. rachel.liminton

    rachel.liminton Active Member

    Thank you all for your comments.......very helpful. Just wondering though, (as opinion appears to be divided) whether to issue my lady with two orthotics for the hallux rigidus foot, one with a kinetic wedge and the other a mortons extension and ask her opinion as to which one appears to be more effective in managing pain and comfort levels???:dizzy:

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