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:
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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 -
They are not effective for hallux rigidus and may even be dangerous!
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Thank you for your advice. Any suggestions for prefab orthotics with inbuilt mortons extension available in the UK? :eek::eek:
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or a full length prefab with no Forefoot posting cut away the Forefoot extension leaving a mortons extension -
What is the pathology you are treating? (i.e. What are the patients symptoms and what is the diagnosis?) -
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 -
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
Sani-grinder
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 -
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:
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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 -
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!
Cheers,
Bel -
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
:drinks -
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 -
http://en.wikipedia.org/wiki/Grandmaster_Flash
http://www.youtube.com/watch?v=O4o8TeqKhgY
(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). -
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..;)
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http://www.youtube.com/watch?v=HwDBZuHw7l8
Enjoy the rest of your weekend:drinks
Bel -
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
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Simon, Kevin is my guru...you can't say that!!!!!:eek:
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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?
http://www.asbweb.org/conferences/2003/pdfs/163.pdf
http://www.health.uottawa.ca/biomech/lab/docs/isb19_kr.pdf
It's pretty much the same as the debate here: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=71007 -
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Sorry Simon ...only jest...interesting about your last post though and kinetic wedges..
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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"? -
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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 -
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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. -
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. -
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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 ? -
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.
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Can I change the bending moment in a bone? You might want to check your definition of kinetics.
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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. -
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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: -
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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