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Func Hallux Rigidus - Could it be this simple?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by adiraja108, Nov 30, 2010.

  1. adiraja108

    adiraja108 Member

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    Hi everyone,

    I have been reading these forums with interest for several years and this marks my first post. I have read many varied and well thought out descriptions of foot mechanics and function both in this forum and throughout the web And enjoy the lively debate.

    I have not seen this particular paper discussed here before.

    Any thoughts from the big boys?

    Sincerely, Adam

    Regarding functional hallux limitus, I have attached a link to a paper below.

    The abstract reads as follows:

    Functional hallux limitus is a frequent, though relatively unknown condition that clinicians may overlook when examining patients with complaints that are not limited to their feet, for they can also present other symptoms such as hip, knee and lower-back pain. The purpose of this article is to present a critical review of the literature on functional hallux limitus and to explain a previously described and simple diagnostic test (flexor hallucis longus stretch test) and a physiotherapeutic manipulation (the Hoover cord maneuver) that recovers the dorsiflexion of the hallux releasing the tenodesis effect at the retrotalar pulley, which according to our clinical experience is the main cause of functional hallux limitus. The latter, to the best of our knowledge, has never been described before. (J Am Podiatr Med Assoc 100(3): 220–229, 2010)
  2. Craig Payne

    Craig Payne Moderator

  3. :welcome: Adam

    we also discussed Functional hallux rigidus is there a term here Functional Hallux Rigidus ??? the conclusion was that as with Functional hallux limitus it´s better to just discribe the 1st MTPJ having increased dorsiflexion stiffness - in this case very stiff.

    Hope that helps
  4. David Smith

    David Smith Well-Known Member

    Page 5 -6 it says;

    “Test for Functional Hallux Rigidus”, showing a restricted MTP1 dorsal
    flexion when the ankle is placed in full dorsal flexion. This qualitative and diagnostic test
    has also been called by Michelson the “Flexor Hallucis Longus Stretch Test” (9).
    For the test to be reproducible and accurate: (Fig 3a,3b,3c.)
    1-Place the patient in supine position.
    2- Evaluate the Range of Motion (ROM) of the MTP1 joint in plantar flexion of the ankle.
    A dorsiflexion of about 50 to 80 degrees is normally present (13). When reduced, a
    degenerative hallux rigidus must be ruled out.
    3-Place the ankle in full dorsiflexion by pushing the foot backwards as much as possible
    with the palm of your hand placed beneath the MTP 1 head, while supporting your bent
    - 6 -
    elbow against your iliac crest. This manoeuver will put under tension the Flexor Hallucis
    Longus tendon.
    4-Test the passive extension of the MTP1 joint by pushing the 1st toe backwards.
    Results : Negative test if the extension of the MTP1 is possible and not restricted.
    Positive test if the extension of the MTP1 joint is restricted or not possible.
    This “stretch test” if positive confirms a tenodesis effect, a limited sliding motion of the
    Flexor Hallucis Longus tendon, that gets blocked in the retrotalar space like a “cork in a
    bottle”(17). Under passive dorsal flexion of the Hallux, the tendon fails to glide and
    constitutes a taut string that produces a specific foot print. (See Fig. 4a, 4b)


    This is a normal response and not an indication of FncHL.
    The plantar fascia origin is in the calc and distally traverses the 1st MPJ joint to its insertion in the proximal phalanx. If you dorsiflex the foot and the 1st ray, i.e. extending the medial longitudinal arch, then the mechanical action of the plantar fascia, regardless of FHL, is to plantarflex the Hallux, the more strain on those tissues the more plantarflexion moment is applied to the Hallux.

  5. :drinks

    I think that is a rather profound observation. Put simply, which is better yet.
  6. Glad you think so as it was you that said it on the thread I started on Functional Hallux Rigidus this year. :D

    or very close here what you wrote.

  7. LOL. Ok.
  8. musmed

    musmed Active Member

    Hi all
    Now you have a diagnosis
    how do you treat it?

    From a cloudy Dunedin
    Paul Conneely
  9. Depends.
  10. musmed

    musmed Active Member

    Dear Robert
    I just saw a website. The question is still not answered.
    I like to know where you got the data that says plantar fasciitis is helped by orthotics as quoted on your site.
    As far as I know and all that attended the National Podiatry conference in 2009, there was no data that supported this idea although there were many many papers of very poor quality that were analysed. The collective outcome was nil for PF, excellent for Rheumatoid arthritis and faily good for OA of the feet.

    Still looking for an answer
    Paul Conneely
  11. Well Done :drinks. What kind of website?

    Oh THAT website.

    Really? Seriously?:confused:

    You want the list? The link to the cochrane database? The deductive evidence?

    Ok, start with this one

    Karl B. Landorf, PhD; Anne-Maree Keenan, MAppSc; Robert D. Herbert, PhD Effectiveness of Foot Orthoses to Treat Plantar Fasciitis
    A Randomized Trial Arch Intern Med. 2006;166:1305-1310.
    Compared with sham orthoses, the mean pain score (scale, 0-100) was 8.7 points better for the prefabricated orthoses (95% confidence interval, –0.1 to 17.6; P = .05) and 7.4 points better for the customized orthoses (95% confidence interval, –1.4 to 16.2; P = .10). Compared with sham orthoses, the mean function score (scale, 0-100) was 8.4 points better for the prefabricated orthoses (95% confidence interval, 1.0-15.8; P = .03) and 7.5 points better for the customized orthoses (95% confidence interval, 0.3-14.7; P = .04).

    And this


    Currently, there is gold level evidence for painful pes cavus and silver level evidence for foot pain in JIA, rheumatoid arthritis, plantar fasciitis and hallux valgus.
  12. Griff

    Griff Moderator

    Craig was the first person who highlighted to me the potential for hallux limitus/rigidus being reconceptualised as a change in dorsiflexion stiffness: http://www.clinicalbootcamp.net/functional-hallux-limitus.htm
  13. Ian:

    I believe we talked about this concept of hallux dorsiflexion stiffness earlier on Podiatry Arena on the Hallux Limitus/Rigidus thread in November 2008.

  14. Griff

    Griff Moderator

    Hey Kevin,

    My bad - I think I may have missed that thread first time round (my arena addiction wasn't quite so terminal in 2008...)

  15. musmed

    musmed Active Member

    What website you say.
    I opened the website you posted and I believe it is yours.
    In your website you say that PF can be helped with orthotics. I say there is no data.
    You give me papers that I have read and I did not see anything related to PF. The data is just not there.

    We have new laws with our National accreditation of 10 professions. These include phsyio, medicine, chiro nursing dentistry psychology osteopathy and podiatry.
    There are specific laws regarding the use of the web to advertise. I would not be happy to carry such information over here in Australia. This all started in september 2010.

    Paul Conneely
  16. Paul, you're being odd.

    Firstly, I didn't post a website, its just a link on my signature.
    Secondly, what's not to see?! I posted the cochrane database. Which is the largest single database of meta-analyses in the world. It states there is silver level evidence for the treatment of plantar fasciitis with orthoses. I posted a good sized RCT, with data.

    Thirdly, What exactly are you talking about the laws for your profession and advertising? You may disagree with the cochrane database but I think you have to to accept that it is a sort of standard reference. What point are you trying to make?

    How is this sentance

    Unrelated to PF? How is the study called
    Unrelated to plantar fasciitis? The clue is in the name of the trial and the fact that the database says "plantar fasciitis" in that meta-analysis. If its not about plantar fasciitis, what exactly IS it about, and what makes you think that you know more about what Dr Landorf's study about than he does.

    If you have a point, please get to it.
  17. Craig Payne

    Craig Payne Moderator

    That is cherry picking the results to make a point. If you look at the results of that study. The two foot orthotic groups did better than the placebo (sham orthotic group) at 3, 6 and 9 months. By 12 months the placebo or sham group had caught up. Not sure how that can be interpreted as foot orthotic can not help plantar fasciitis. That evidence says that foot orthotics DO help plantar fasciitis and that the natural history of plantar fasciitis is to get better over 12 months. That study shows you do better with the foot orthotics.
  18. Sorry Craig, what Is cherry picking results? I agree with what you say about the study. Clearly helped.
  19. Craig Payne

    Craig Payne Moderator

    Cherry Picking:

    I have seen many people use Karl's study to show foot orthotics don't work. They do that by 'cherry picking' the 12 months data which showed no differences, yet ignore the data at 3, 6 and 9 months that the foot orthotic groups did better. The study showed that foot orthotics work and the researchers in the study will state that.
  20. Oh right. Sorry, I thought you meant me.

    Thing is, Paul said

    whatever you take from that data it is still related to pf! That's why I'm confused!

    But yes. Improvement over 3 6 and 9 months is clearly "help". Paracetamol for headaches performs the same as tic tacs after 7 days!
  21. musmed

    musmed Active Member

    Hi all
    Thus at 12 months the scores are equal. Thus is it time that cures all?

    The lecture I was refering to was presented by a young lady doing her PhD on orthotic use.
    She presented a metanalysis of many papers involving some 1500+ souls (joke Joyce).
    The evidence she had was
    Most studies were poor. These were from the group she included. Many were excluded because they did not fit her criteria to perform a study.
    Most studies had no outcomes.

    Is Cocherane always correct?
    Paul Conneely

    the same applies for the use of corticosteroids for lateral elbow pain, tennis elbow.
    At 6 months those treated with steroids are just as sore as those who had nil therapy.
  22. Yes. Same goes for almost any soft tissue injury I suspect. :eek:

    Paul, first you tell me that there is NO data. Then you say there IS data but that its low quality.

    You say that you "did not see anything related to PF". Now you say that you DO see something related to PF, but you don't like it.

    You question the the statement that orthotics help PF based on the fact that the outcomes are the same after 12 months in that study, in spite of the fact that they are clearly and significantly helpful at 3, 6 and 9 months. Helpful up to 9 months is still helpful isn't it. I have a stiff neck at the moment. If someone offered me a treatment which was shown to work up to 9 months I'd take it thankyou very much!

    So what do you suggest Paul? That we ignore the clear benefit up to a year and the data within the cochrane database and stop giving people orthoses for PF?

    If you don't like the statement that orthotics can help PF, how would you feel about the opposite. How about
    Is that consistant with the evidence in hand?

    What would you suggest would be better? Or should we stop treating patients altogether?

    I ask again. What is your point? Granted that the evidence for PF is imperfect , (though pretty damn solid).If a patient comes in to you with a painful PF what treatment would you offer which has a stronger evidence base than orthoses?
  23. musmed

    musmed Active Member

    Dear Robert
    Maybe I was wrong in saying there is no evidence but I was going on what the PhD lady was talking about.
    She presented data from cochrane, medline, pubmed and several other site where she collected her data from.
    This collected data was displayed on the screen. It was referenced so I wonder why the data has changed in about 1 year.

    What made it go from poor to 'pretty damn solid'.

    maybe climate change.

    You mentioned thaqt soft tissue injuries get better with time. That is why the problem here is with the amductor hallucis in the first place.

    If you reqd the lastest on pod arena about achilles rupture: surgery vs active rehab.
    at 14 months no difference.

    I suppose we will all be out of a job soon
    Paul Conneely
  24. Maybe you were. If you are going to make a case which is not your own in such an aggressive way, you should have a solid grasp of it.

    Hard to say without seeing that data! But those studies are not less than a year old. You can't make a case based on a hazy recollection of data you saw for 60 seconds on a powerpoint presentation of an unpublished meta analysis delivered over a year ago at a conference.

    You're going to have to explain that. I don't know what the problem with the amductor hallucis is.

    It is what it is. What's your point? What are you getting at Paul. I have a good deal of respect for you, by proxy, because someone whose opinions I value rates you very highly. But you just can't come in shouting the odds like this without following through! Are you getting to a point, perhaps about PF being caused by a problem of the abductor (or adductor) hallucis? If so by all means lets have it and we'll put it all out on the table and look at it. And lets stop with the sniping. :drinks
  25. musmed

    musmed Active Member

    Dear Robert
    Thank you for your reply.

    I actually have these notes from the workshop but currently an in Dunedin NZ to teach foot mechanics on the weekend.
    I will see if the link to the presenters is still around and if so i will send it to you.

    Regarding the abd. hall.
    I did a 2 year study on this muscle with 64 people who had the classic PF foot.
    Got out of bed and walk on glass etc.
    The am it take 7-9 steps to reduce the pain and the lunchtime foot takes 3-4 steps.
    The only thing that changes is muscle tone. I have written about this before.

    If you ultrasound the muscle in the am is it take the patient 7-9 goes to activate the muscle. at lunch time it take 3-5 goes. This is easily seen on u/sound

    The other thing we found is 50% had the muscle fibrillating when at rest. No other lower limb muscles were doing this when we passed the U/sound head over the lower limb muscles.
    Why I do not know. I jsut tell patients that it is a sick puppy.

    I dry needled the muscle in the mid belly which is between the medial malleolus and the navicular notch
    I use a 30mm 0.3mm acupuncture needle
    I insert it 25mm and leave it 10 secs.
    sometimes you get a twitch response (we recoreded all of this on U/sound)
    sometimes nil
    in 10 mins thew cross sectional area goes down 12.5% and the muscle changes colour towards normal.
    60% had immediate cessation of their pain and it did not return.
    Dr. H Danenberg has written about this on pod arena.
    Try it. tell them that it will hurt. Normal muscle= needle it= no pain. Unhappy muscle= needle=pain

    If it works you are ahero if not you lost 10 secs and a cheap needle.

    I have needled several hundred of them with patient having the problem from a few weeks to upwards of 10 years.

    The sun has just come out here, going for a walk.
    Paul conneely
  26. That actually sounds really quite interesting. I might just look into that.
  27. joejared

    joejared Active Member

    I've seen 5 methods from 5 different labs. The most common methods I've seen have been first metatarsal or ray cutouts of varying styles into the foot orthosis. One practitioner required some additional design work, which included stretching the extrinsic forefoot proximal of the cut-out to reinforce the device.

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