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Foot orthoses for functional hallux limitus

Discussion in 'Biomechanics, Sports and Foot orthoses' started by lalsam, Mar 11, 2006.

  1. lalsam

    lalsam Welcome New Poster

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    Hi all,
    can anyone tell me the prescription and rationale for the use of a functional orthoses in the long term management of functional hallux limitus, I seem to be getting confused, is the orthotic the same for hallux limitus/rigidus.
    thanks :confused:
    2nd year student.
  2. Craig Payne

    Craig Payne Moderator

    Firstly be very clear on definitions, so we speaking the same language:
    Hallux rigidus - no motion at first MPJ
    Structural hallux limitus - reduced motion at MPJ both weightbearing and non-weightberaring
    Functional hallux limitus - adequate ROM non-weightbearing, but appears to have inadequate ROM (even temporarily) during weightbearing.

    The orthoses prescription for a structural and functional hallux limitus is very different.

    In a structural hallux limitus, the ROM can not generally be altered by an orthoses (manip and mobs may be able to), so prescriptions tend to incorporate a mortons extension or some kind of rocker to prevent the full range of motion of the joint (if its problematic) and faciliate sagittal plane motion.

    In a functional hallux limitus, the ROM can generally be altered by an orthoses and this will involve anything to plantarflex the first ray; ie:
    Invert the rearfoot (wedging or posts)
    Plaster modifications to positive model for steeper slope to shell under medial column
    First ray cuts outs (big ones)/thinner shell material below medial column
    Kinetic wedge
    Cluffy wedge/pre-load the hallux
    Plantar fascial groove (deep and anterior)
    Forefoot valgus posts/2-5 bars/reverse mortons/met domes
    Lateral column support
    Heel raise
    Windlass enhancing running shoe
    Last edited by a moderator: Mar 11, 2006
  3. Admin2

    Admin2 Administrator Staff Member

  4. philbrizell

    philbrizell Member

    I'm I correct in saying that a first ray ray cut out and a first met cut out can be used for FH Limitus, to promote first ray plantar flexion and the Hicks Windlass mechanism - If my assumptions are correct, what would make you use a first ray cut out over a first met cut out and vice-versa?

    Many thanks

    ( I'm sure that theres some quotation out there which says its best to ask a question and look stupid for a few minutes, but by asking, one learns and becomes wiser by the receiving of an answer. Than not asking a question and remaining ignorant for the rest of your life)
  5. David Smith

    David Smith Well-Known Member

    I would use a met cutout when the 1st met head is lower than the 2-5 heads. This off loads the mpj especially when used in conjunction with a 2-5post or reversed moton's post (ie a even thickness post extended to the met sulcus fro 2nd to 5th mets.)
    A first ray cut out or reducing the level of the shell at the first ray will result in there being no vertical orthosis reaction force, dorsiflexing the first ray, from the met head up to the nav cuneiform joint. This will enable the plantarflexing moment of the 1st ray plantarflexors to have more effect and allow the 1st ray to become resistant to GRF at the correct time and position in the gait cycle. Also increasing the capability of the windlass action of the hallux which enhances resupination of the rearfoot.
    A 1st met cut out may also achieve this but on the other hand it may only accomodate the low position of the met head, which depending on the stiffness of the first ray may result in reduced lesions or reduce early supination of the STJ.
    So it all depends on the type of foot and what you wish to achieve.
    A cavus foot type with valgus forefoot and stiff 1st ray with low met head, for instance, might require a 1st met cut out and lateral 2-5 post.
    However a 1st ray cut out, along with medial posting will usually be applied to a low arched plantarflexed foot with a 1st ray compliant to GRF, which may also have FnHL.

    "I'm sure that theres some quotation out there which says its best to ask a question and look stupid for a few minutes, but by asking, one learns and becomes wiser by the receiving of an answer. Than not asking a question and remaining ignorant for the rest of your life"

    I always say "If you want to win you must be prepared to lose"
    In Judo it is said "you only learn when you lose"
    In diving we used to say " look silly on the surface, get run off (lose your job) at 100 Metres"
    How about "pride comes before a fall" or "wisdom comes quickly and too late"

    Its good philosophy however you phrase it.

    How about this bit of philosophy which is a favourite of mine.

    Faith is the antithesis of proof thats why I believe in science!

    Cheers Dave
  6. Phil Wells

    Phil Wells Active Member

    What's a Cluffy Wedge?

    Also Phil, be aware that 1st ray Cut outs may allow the orthoses to move medially in the shoe. I have never totally understood why this occurs in some patients and not others but I have a feeling that it may be caused by propulsive phase mechanics. Also possible is the change in GRF vectors in response to STjt plantar axis location. I am sure if I think hard enough I will be able to convince myself of a possible answer but in reality I seldom use them and opt for cast corrections instead.

    Phil W
  7. Ian Linane

    Ian Linane Well-Known Member

    Hi PhilB

    The adage you were wanting has served me well over the years, especially when asking questions that everyone else seemed to know the answer to:

    "If I ask a question I'm a fool for a minute, If I don't I'm a fool for life"

    at least that was how it was put to me.

    Mind you, I sure there are many who would still consider me a fool in many ways.

  8. Craig Payne

    Craig Payne Moderator

    Preloading the hallux is somethng I do a lot of - its simply is padding/EVA/whatever that holds the hallux in a slighlty dorsiflexed position. James Clough has a trademark or patent on it (can't recall which) - called the Cluffy Wedge.
  9. philbrizell

    philbrizell Member

    Thank you gentlemen for your replies and also for your pearls of wisdom! :rolleyes:

  10. Footsies

    Footsies Active Member

    Cluffy Wedges

    I was just wondering if there has been any long term studies into CLuffy wedges? I know they are a relatively new thing...but i am just a little concerned as to the long term affect on the Joint? :confused: Would placing the hallux in a dosiflexed position over a long period of time cause EHL shortening +/ jt changes??
  11. Craig Payne

    Craig Payne Moderator

    There have been no studies. BUT, when I preload the hallux, I only talking about 3-4mm, so would assume its not enought to cause any shortening. Have not seen any short or long term problems so far.

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