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Functional hallux limitus in forefoot varus - solution?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by maxants33, Jun 14, 2015.

  1. maxants33

    maxants33 Active Member


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    Me

    Hello
    I'm a Band 5 NHS pod looking for help with a case - I'm a recent graduate and this case might be straightforward, but I don't do much Biomechanics in my current post but really want to improve. Any feed back would be super appreciated.

    Patient
    The patient is a 28 year old female with no significant medical history or meds.

    She is complaining of pain and callus under both 5th MTPJs, as well as "little bunions" on both 5th MTPJs. Pain is confined to both 5th MTPJs and only occurs after walking 'for a while'.

    Patient works in an office but does a lot of walking over the day.

    Findings
    On examination she has a pronated stance on both feet with significant splaying of the rays. Non-weighbearing shows a 'neutral' rearfoot position with a quite obvious forefoot varus (aprox 15 to 20 degrees). Very mobile feet and moderate hypermobility bodywide. Both feet have advanced tailors bunions.

    Callus is present plantarly on both 5th Met heads and on both hallux IPJs with slight osteophyte formation on both 1st Met heads. Both hallux motion is great (+ 70 degrees) and no adbductory deviation or pain present. Functional hallux limitus evident in weightbearing.

    All RoMs in both feet normal to extra mobile.

    Footwear is sensible - lace up brogues but weightbearing foot is splayed enough that there must be a 1cm shortfall in frontal plane space in the shoes.

    Opinion

    The excessive weightbearing on the 5th is 'unlocking' (term used with caution) the mid tarsal joint and causing extra mobility and callus build up, dorsiflexion of the 5th ray with combination of medial pull from flexor tendons and medial push from footwear has caused a tailors bunion.

    Mobileforefoot + dorsiflexed position of 1st Ray is inducing a functional hallux limitus in gait, resulting in IPJ callus buildup


    My goals are to alleviate the excessive 5th MTPJ weightbearing and improve foot posture so as to prevent both 5th and 1st rays from degenerating any further.
    ________________________

    Treatment?:dizzy:


    Naturally I felt the best option would be forefoot medial wedging, as that would eliminate many problems here. BUT where does that leave the 1st ray and hallux limitus?

    I was always under the impression the goal was to assist plantarflexion of the 1st ray to unlock that necessary 1st MTPJ motion - but forefoot wedging would surely have the unwanted effect of further blocking the plantarflexion of the 1st metatarsal? And the hallux is asymtomatic, I dont want to block it further and cause new problems.

    How can you wedge the forefoot but avoid messing with the 1st ray?

    Would building up the arch element lift the navicular which would allow the 1st Metatarsal to drop relative to it?

    Are further observations needed - e.g identifying STJ axis?



    Thanks

    Any help would be great, if I can do well on this patient it would really help my learning and get me feeling 'more gooder' about doing biomechanical cases!
    Many thanks!
    Max
     
  2. efuller

    efuller MVP

    Re: Functional hallux limitus in forefoor varus - solution?

    That is a classic description of a partially compensated varus. In the partially compensated varus the patient will often plantarflex the mpj to increase medial weight bearing. Her problem is too much force on the fifth met head. You correctly identified the correct treatment. Your question becomes did I overcorrect? The amount of wedge needed is difficult to measure. I would suggest trying wedges of various heights and seeing what she likes best. This sounds like a foot that needs more force under the first Ray. You probably have a long way to go before you cause first Ray problems

    Eric
     
  3. Matti Ollikainen

    Matti Ollikainen Welcome New Poster

    I'm a lay person in podiatry with a gp schooling. Perhaps this video https://m.youtube.com/watch?v=1iZg_e4veWk might be of some aid. The logic behind the exercise is obvious. I've yet to master it but have observed some help with a varus disability of the right foot. My own diagnosis though.
    Matti Ollikainen Finland
     
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