First MTPJ Manipulation

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HI ALL

Please could you enlighten me on some info on manipulating the 1st MTPJ to increase ROM.
A colleague who had aattended a biomech summer school, explained to me that sometimes alot of limitation around the first MTPJ is soft tissue contracture which can be manipulated and technically stretched to increase ROM.

She went on to demonstrate a technique of pulling the first met and proximal phalanx apart as if opening the joint space and then dorsiflexing and plantarflexing the joint.

Please tell me if this is correct? is there any evidence base? is there a standard technique? Is there anywhere on the net that i can find this?

Thanks everyone, sorry for all the questions.

Best Wishes

Cheryl

 

Cheryl,

This is a mobilization technique. I wouldn't suggest "manipulation". Hold the proximal phalanx of the hallux with one hand and the metatarsal head/shaft with the other. In the neutral position gently pull on the hallux in soft repetative pull/release action. Dorsiflex the Hallux to it's soft end range and do the same - plantar flex to it's soft end range and do the same.

This should be done in conjunction with orthoses with a Fnhl accomodation. any posting directly under the first ray/mtpj will negate any improvement with the mobilisations

Regards

 

Hi Cheryl:
Just one word of caution with the 1st MTPJ......
It is not unusual for patients with hallux limitus / rigidus to have someone try and manipulate their MTPJ only to have an osteophyte fracture. The dorsal-lateral spur at the base of the proximal phalanx is the most common site. This spur tends to be a bit fragile and cracks on forced dorsiflexion.

Steve

 

Cheryl

Here's a technique I use, which works well most of the time.

Right foot - Fully dorsiflex the hallux, with left hand grip the toe like this -

With the plantar foot facing you - place forefinger between 1st interspace and curled around dorsal base of proximal phalanx. Thumb placed on plantar aspect of distal phalanx. Get the patient to forcibly plantarflex the toe against your resistance. After a few second get the patient to relax and as they relax dorsiflex the hallux with your thumb and distract the base with your forefinger. You will feel the hallux go thru increased RoM immediately.

Cheers Dave

 

Unlike manipulating the cervical spine for instance, don't we think the clinical/therapeutic forces (of manipulating/mobilising 1st MPJ) are akin or inferior to the forces of body-weight, GRFs etc. So what is the real downside of MPJ manipulation if you respect pain, irritability and tick the boxes in the history?

In other words, unless you are dealing with an early post-surgical or fusion, I don't think there is much to lose by having a 'go' at the first MPJ. It can't be super acute, and it can't be pain > stiffness. Some of the techniques mentioned though seem appropriate and worth considering.

But in addition to seeking confirmation/condemnation from peers on this site, it is equally and perhaps more valuable to judge the effect on your patient; subjectively and objectively if possible.


Ron
Physiotherapist (Masters) & Podiatrist

 

Wise words

 

I like to think of any manipulation of the 1st MTP joint as a two part process. First, always check strength in the peroneus longus. Since this is the primary stabilizer of the 1st ray, any inhibition can negate any affect you may have with any 1st MTP joint manip. The fastest approach is to first mobilize the proximal fibula head, and then the ankle. This will often restore normal facilitation to the peroneals.

For the 1st MTP joint itself, I usually have the patient gently dorsiflex their hallux as it is gripped and gently distracted. Then, the mobilization is performed at the met-cuneiform joint with a gentle thrust across the dorsum of the base of the 1st met. ROM at the MTP joint will often respond. These patients will need f/u orthotics with some type of 1st ray c/o. Over time, this condition can improve substantially in most, but certainly not all cases. Taking an immobile joint and trying to make it move during walking can cause pain in some patients. NSAID's are very suitable for the initial 10 days of treatment, as it can ease this pain from initial mobility.

These manipulation are available on the Vasyli website at www.vasylimedical.com. I am a paid consultant to Vasyli.

Howard