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Functional Hallux Limitus, my project so far...

Discussion in 'Biomechanics, Sports and Foot orthoses' started by vegetableplots, Jan 26, 2009.

  1. Members do not see these Ads. Sign Up.
    Hello everyone,

    I am currently studying osteopathy in the UK and I am in the process of researching for my dissertation.

    After various discussions I have decided to look at the subject of FHL, the structural assessment we are taught often neglects the importance of the foot, especially in its functional position i.e. weight bearing.

    With the loss of such an important sagittal plane motion in FHL it seems that it should be taken into account, especially when the majority of our patients present with pain in sagittal plane dominant areas of the body i.e. the low back and knee.

    As of yet I am still doing my critical literature review, and I am still unsure of the question I would like to answer.

    I have had a few ideas:
    •“Are Osteopaths within the UK aware of FHL and the effects it can have?”
    •“Is there an association between FHL and non-specific chronic LBP?”
    •“Are patients within our clinic who suffer from chronic non-specific LBP also suffering from FHL?”

    I would prefer to do a review within the subject, so if any would like a particular area of this subject reviewed or have any ideas, give me a shout.

    Will keep the post updated as I go.

  2. Smilingtoes

    Smilingtoes Active Member

    Have a look into Howard Dannanburgs works. i personally see direct relationships between this foot pathology and back symptoms anacdotaly
  3. Smilingtoes

    Smilingtoes Active Member

    Halleluiah! Great to have you on-board. :drinks

    Have a look into Dr Howard Dannenberg DPM works. I personally see direct relationships between this foot pathology and back symptoms in clinic and when treated often relieve chronic back symptoms. Suggest you search his name through google schollor and PubMed.

    Let us know how you go.:empathy:
  4. Suggest you spell his name correctly when you do your search, it's Dananberg. As Howard contributes here, you may get it straight from the horses mouth....
  5. Thanks for the idea below are a list of papers i have been reading through already:

    # Chapman C, 1999., Functional Hallux Limitus – the essentials. British Journal of Podiatry. 2(2);40-44

    Claeys, R., 1983, The anaylsis of ground reaction forces in pathological gait, international orthopaedics, Spring 113-119.

    # Dananberg, HJ, Guiliano, M, “Chronic lower back pain and its response to custom foot orthoses” Journal of the American Podiatric Medical Association, 89:3 March, 1999 pp109-177

    Dananberg, HJ, “Functional Hallux Limitus and its relationship to Gait efficiency” Journal of the American Podiatric Medical Association. November 1986

    # Dananberg, HJ. “Gait style as an aetiology to chronic postural pain. Part 1: Functional Hallux Limitus. Journal of the American Podiatric Medical Association. 83(8):433-441. 1993a.

    Dananberg, HJ., 1995 Lower extremity mechanics and there effect on lumbosacral function. Spine review 9(2):389-405

    # Dananberg, HJ,. DiNapoli DR. Lawton M. 1990 Hallux limitus and non-specific bodily trauma, In: DiNapoli DR (ed.) Reconstructive Surgery of the foot. Podiatry institute, pp52-59.

    Dananberg, HJ. 1985 Functional Hallux Limitus and its effect on normal Ambulation, April, The Journal of Current Podiatric Medicine.

    # Dananberg HJ. 1993b. Gait style as an etiology to chronic postural pain. Part II: the postural compensatory process. Journal of the American Podiatric Medical Asscoiation 83(11):615-624.

    Dananberg HJ. Lower Back pain as gait related repetitive motion injury. In:Vleeming A, Mooney V, Dorman T, et al, eds. Movement stability and lower back pain. Edinburgh: Churchill Livingston 1997: pp 253.

    # Dananberg HJ., 2000. Sagittal plane biomechanics American Diabetes Association. Journal of the American Podiatric Medical Association, Vol 90, Issue 1 47-50.

    # Drago JJ,. Obff L., Jacobs AM. 1984. Comprehensive review of hallux limitus., Journal of foot surgery.;23;213-220.

    # Grady JF, Axe TM, Zager EJ, et al. A retrospective analysis of 772 patients with hallux limitus. J Am Pod Med Assoc Vol 92:102, 2002.

    # Hall C, Nester CJ PhD., Sagittal Plane Compensations for Artificially Induced Limitation of the First Metatarsophalangeal Joint A Preliminary Study. American Podiatric Medical Association.

    # Halstead J, Turner D, Redmond A. The relationship between hallux dorsiflexion and ankle joint complex frontal plane kinematics: A preliminary study. Clinical Biomechanics, Volume 20, Issue 5, Pages 526-531

    # Halstead J, Redmond AC. 2006. Weight-bearing passive dorsiflexion of the hallux in standing is not related to hallux dorsiflexion during walking. Journal of Orthopaedic Sports Physical Therapy. Aug;36(8):550-6.

    Hicks, JH. 1954. The mechanics of the foot. Part II: the planer aponeurosis and the arch. Journal of anatomy 88: 25-30.

    Laird PO. Functional Hallux Limitus. Illinois Podiatrists 9:4,1972.

    # Lichniak JE. 1997. Hallux limitus in the athlete. Clinical Podiatry Medical Surgery. Jul;14(3):407-26.

    # Scherer PR, Sanders J, Eldredge D, Duffy S, Lee R. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Pod Med Assoc 96: No 6, 474, 2006.

    Schiller JE. 1987. Functional hallux limitus and gait efficiency. Journal of American Podiatry Medical Association. May;77(5):268-9.

    Sherman G. 1993. Functional Hallux Limitus. Journal of American Podiatry Medical Association. Dec;83(12):698-9.

    the ones with a # sign i have sourced and read, the others i am still looking through.

    Found this one quite interesting dont know if you guys have seen it: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005275/frame.html.
    Last edited by a moderator: Jan 27, 2009
  6. efuller

    efuller MVP

    Hi John,

    Do you have access to a gait lab that can do joint power measurements?

    There is currently a debate on the mechanism of FnHL and low back pain. There is the direct mechanical effect "sagittal plane blockade" camp. My problem is that I can't remember their argument because I'm in the other camp, the pain avoidance causes gait changes.

    Both camps agree that functional hallux limitus occurs. That is there is normal range of motion non weight bearing and essentially 0 dorsiflexion of the hallux in gait. Both will agree that with orhtotic treatment you will decrease the hallux limitus and tend to increase walking speed.

    The "pain avoidance" camp theory goes like this. The limited motion of the MPJ is caused by high tension in the plantar fascia. (Weight bearing causes high tension in the fascia.) Any attempt to lift the heel off of the ground will cause even higher stresses in the fascia and compression of the joints. Over time the individual learns that walking with heel lift, or ankle joint push, will increase the stress on the foot and would cause pain if they persisted. Yet, you still have to make the back leg become the front leg to walk. So, if you cannot use ankle push, you will pull the leg forward with the hip muscles (Ilio-psoas). The Ilio-psoas attaches to the low back and when is activated will increase stress on the low back and hence back pain.

    The above can measured through the concept of joint power. High ankle push would be a high ankle power and high amounts of hip pull could be seen with high amounts of hip power. The concept of joint power could be used to answer this debate.

    There are probably theads on this list that go into the debate.


    Eric Fuller
    Regardless, good luck on your research.
    Last edited: Jan 27, 2009
  7. Thanks for the reply eric,

    I am not sure why there are two camps, I’m under the impression that FHL can have many causes such as a hypermobile first ray not just increased plantar fascia tension. And also by definition the 1st MPJ is asymptomatic, therefore why would there be pain avoidance?

    Are both camps in agreement that there is a “sagittal plane blockage”? as by definition FHL is restriction of sagittal plane motion (dorsiflexion) which will presumably require adaptation elsewhere in the body.

    And if there is a sagittal plane blockage it is possible that the iliopsoas muscle is not loaded correctly during gait (eccentrically) and therefore has to use an inefficient contraction (concentric) to manoeuvre the lower extremity, and this can lead to shortening and or tightness of the iliopsoas, which has intimate connections with the lumbar spine not just that the iliopsoas is activated?

    Unfortunately our university does not have much access to any electrical equipment for research. However I edging towards a questionnaire study to look at: “Are osteopaths aware of the implications of FHL”

    Would be interested to know your thoughts and also what you thought of the paper I left a link to earlier.

  8. "Implications for practice
    There is strong evidence against using insoles for the prevention
    of back pain.
    The current evidence on insoles as treatment for low-back pain
    does not allow any conclusions.
    Implications for research
    Additional high quality trials must be done to determine if insoles
    are effective in the treatment of back pain.
    Researchers should improve the quality of methodology and reporting
    of trials on insoles for back pain."

    That's what the research they reviewed suggests, what do YOU think?
  9. efuller

    efuller MVP

    When you have an observable phenomenon and then you try and explain it you will often get different explanations. There are probably more than two camps.

    When you try to explain a phenomenon you have to define the terms that you use to explain a phenomenon. What is a hypermobile first ray and how do you differentiate it from a normally mobile first ray. When you get through with that you then have to describe how a hypermobile 1st ray limits hallux dorsiflexion.

    Dorsiflexion can be limited by a plantar flexion moment. Tension in the plantar fascia as it attaches to the base of the proximal phalanx and force from the head of the metatarsal acting on the proximal phalanx will create a force couple that will limit hallux dorsiflexion.

    Do you hit your thumb with a hammer? That is a form a pain avoidance, as you know it will hurt. It is asymptomatic because you choose/chose not walk in such a manner that it would hurt.

    Again a definition problem. Is sagittal plane blockage and observable gait pattern or is it a measurable mechanical effect. A direct mechanical effect should have an explanation that involves forces and moments. In my description above of the forces acting on the hallux I described how forces could limit dorsiflexion of the toe. That explains why sagittal plane motion of the hallux is blocked. So, yes both camps agree that there is sagittal plane blockage of the hallux. You can describe it, or you can go further and explain it.

    Now your talking about the hip and not the 1st MPJ. How does limitation of 1st MPJ motion effect the hip? This is where the difference in the two camps comes in. It is theoretically possible that lack of hip extension does not preload the Illio psoas so there is a less than optimal contraction of the muscle. I don't believe that this is likely.

    To walk, you need to make the trailing leg become the leading leg. Energy from somewhere is required to do this. Winter has shown through his gait power studies that there is a trade off between hip pull on the swing leg and ankle push of the swing leg. The more ankle push, the less hip pull is needed and vice versa. In functional hallux limitus you see very little ankle plantar flexion which means that there is little ankle push. Therefore, more hip pull is needed. With a greater need for hip pull there will be increased stress on the Ilio-psoas and its attachments.

    Yours is an easy research question, but I'm not terribly interested in the answer.


  10. :D Agreed!!!!!!!!!!!!!!:D Well said :drinks Single question questionnaire! What the world needs now is more people selling foot orthoses, who don't have the faintest idea of what they are doing.
  11. Dananberg

    Dananberg Active Member

    Having lectured to many medical groups (including osteopaths) over the years, I would imagine that there are some who understand the foot/gait/lower back pain relationship. Generally, I would think that this is a relatively small number.
    Those who treat LBP understand that with various clinical and therapy oriented treatments, the symptoms tend to resolve, only to return some time later. Dayo described a 71% relapse rate within 12 months for those who experience a lower back “attack” at some time in their lives. With this in mind, I have learned to look at lower back pain (LBP) as more of a process than a specific lumbar spine/lower back entity. In other words, the stress applied to the lower back during walking is highly repetitive in nature (5-8K steps/side/day), and if unaddress, will either promote or perpetuate symptoms over time.
    Lower back pain can be thought of as the result of “dragging” the limbs, vs. being propulsive during gait. Limbs of the lower extremity weigh 15% of body weight. The mechanism to begin swing phase requires the trailing limb reach full extension by the end of single support phase. With opposite heel strike, the trailing limb immediately reverses from extension to flexion. The more extended it was, the greater the ROM for forward flexion to develop. Conversely, the less extended, the less ROM is available for adequate flexion acceleration to develop during the pre-swing phase. Think about it as trying to throw a ball without reaching back. Without pre-load, the action becomes far more difficult.
    The structures which fires at toeoff are the iliopsoas, and by design, should perpetuate the acceleration of the limb into swing phase rather than create it. An overuse situation if limited flexion exists. Since the iliopsoas originates from the LS spine and crest of the ilium, symptoms of overuse will be felt at the site of origin….in the lower back!
    The principles of sagittal plane mechanics suggest that by increasing the available ROM of the foot during single support phase, hip extension will increase as well. In a study I published for the 3rd World Congress on Lower Back Pain, ROM actually increased approximately 50% (7 to 13 degrees) with the use of foot orthotics specifically addressed to manage Functional hallux limitus. (Dananberg, HJ, Guiliano, M, “Gait Mechanics and Their Relationship to Lower Back Pain”, in Proceeding of 3rd Interdisciplinary World Congress on Low Back and Pelvic Pain, Vleeming, A, Mooney, V, Tilscher, H, Dorman, T, and Snijders, C, November, 1998, European Conference Organizers, Rotterdam, Holland).
    I hope that this begins to answer your questions regarding Functional hallux limitus and lower back pain. Let me know if you have additional questions.
  12. efuller

    efuller MVP

    Brilliant observation. I agree completely.

    I agree with the dragging concept. However, I disagree with the reaching back to throw analogy. In walking the goal is to put the trailing leg in front the body so that it can become the leading leg. The farther the leg trails behind, the more energy it needs to catch up and pass the body to become the leading leg. In throwing you need more time or distance to accelerate the ball. In putting the leg in front of the body, you only have to move the leg the required distance.

    If the iliopsoas is the only structure moving the leg forward then the iliopsoas will have to work harder if there is more hip extension prior to swing.

  13. Dananberg

    Dananberg Active Member


    Here is my take on swing phase. If the trailing limb fully extends at the hip, when the forward leg contacts the ground (end of single support), the trialing leg will simply accelerate forward based on 1) quad tension from hip extension, 2) calf contraction (ankle push), and 3) spinal engine return of energy. Since the iliopsoas fires AT TOEOFF...and not prior to it, the more pre-swing (and relatively effortless) motion, the less work the iliopsoas has to do. The less the hip extends during single support, the less "effortless" forward flexion is available, therefore creating an overuse situation on the iliopsoas.

    It is really about timing and motion...not simply motion.

  14. Smilingtoes

    Smilingtoes Active Member

    Dreadfully sorry.
    Hope this wont discredit my suggestion or the good Dr Dananberg.
    Thanks for fixing my blunder Simon.
  15. efuller

    efuller MVP

    Rectus femoris, the only part of the quads that crosses the hip, has range of motion to allow shank fully flex on the thigh. (ie the heel can touch the butt.) So, the tension in the created by hip extension will have to be created by activation of the muscle and not the passive stretch mechanism of the muscle. Also this seems unlikley because activation of rectus femoris will create a knee extension moment at a time of knee flexion.

    Will the structures that constitute the spinal engine also be stressed more or less with greater amounts of hip extension?

    It's about timing, motion and forces.

  16. Dananberg

    Dananberg Active Member


    This will be my last post swing phase. We have gone round and round over the years....and I just do not have the time to continue that type of discussion. You are certainly welcome to come up with scenarios of your choosing...I am just not going to respond.

    When single support transitions to double support, the trailing limb stops extending and reverses to flexion. Between the onset of terminal double support and the ensuing toeoff, pre-swing motion of the trailing limb occurs. This is a complex action created by a combination of energy storage/return and muscle activity. The effect of pre-swing is to take the trailing limb and accelerate it rapidly enough to make toe-off into swing phase as effortless as possible. The greater the amount of hip joint extension during single support, the more acceleration possible during pre-swing. The less the hip joint extends during single support, the less available motion for pre-swing, and the harder the iliopsoas must work to create an effective hip flexion. It is far easier to provide a burst to a limb already in motion than to accelerate it from a static position. Considering the origin of the psoas is the LS spine, the discs and intervertebral septa...repetitive stress to the spine from a failure to properly initiate swing phase is a very predictable response.

  17. Hi Eric FHL is not just an observable phenomenon but an objective dysfunction.

    And the reason I do not hit myself with a hammer is because I have experienced that pain. However if FHL isn’t painful then why would I want to avoid that movement to avoid pain?

  18. Thanks for that information Howard, in our clinics we do see a lot of Non-specific LBP patients and there is a vast array of opinions on how to treat the LBP – I am hoping that this study will be further progress in identifying a lack of biomechanical knowledge base within the profession, which hopefully we can then address.

    I can see the concept of pre-load, however whilst doing an EBM review I also would like to look at a few papers published on the subject, as of yet I have only found one or two which look at increased power with greater preload, however none to do with energy effecient gait so far could you recommend any?

    Thanks again

  19. The research actually states "There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities."

    "while the current evidence on insoles as treatment for low-back pain does not allow any conclusions."

    With looking at EBM the research often states "Additional high quality trials must be done". However i feel that it was a shame H.Dananbergs study didnt fit the criteria to be placed in the review and that the orthoses used where not specifically designed to address the LBP.

  20. Dananberg

    Dananberg Active Member


    The problem with "inserts" and previous LBP studies is that the researchers are trying to find some "universal type" of device that will solve this issue, rather than recognizing that it is the individual Rx for a custom foot orthotic that is effective. The approach taken to date is like trying to solve eye issues with a universal eyeglass Rx. This will never work, yet LBP reseachers expect that some type of different outcome for foot orthotics. Boggles the mind!

  21. David Smith

    David Smith Well-Known Member

    Howard - Well said

    Unfortunately this is the claim or goal of many podiatrists in the world IE A single design fixes everything for everyone.

    Cheers Dave :good:
  22. David Smith

    David Smith Well-Known Member


    I am a great proponent of the saggital plane theory and this is central to my treatment of most of my patients and orthosis design. However having read most or all of your papers on the subject of saggital plane progression and its connection to pathology in gait and LBP I cannot understand the concept that you put forward above, especially the concept that as saggital plane block increases, ilio-psoas tension increases and so therefore does its injury rate. Despite discussing it with you previously on Pod Arena I still don't get it. Can you reccomend one of your papers that explains the concept the best.

    Cheers Dave
  23. The research actually states what I cut and pasted from the document , p.8 under Author's Conclusions ;)

    I've attached the full paper so people who may not be able to get access to the full text can view it.

    Why didn't it meet the criteria for inclusion?

    Attached Files:

  24. Dananberg

    Dananberg Active Member


    I think that its not the issue of iliopsoas "tension" that causes LBP, but rather a chronic overuse of the iliopsoas based on repetitive strain. Let me try to explain this.

    1. As I understand iliopsoas firing, this is the "hard wired" component gait. At toeoff of the trailing limb, the iliopsoas (IP) will fire. This is likely linked to impact of the opposite side...but this is speculation on my part.

    2. Since the IP is firing regardless of the position of the hip and thigh, it will act whether or not the trailing limb is smoothly and efficiently moving during the pre-swing phase of motion.

    3. The IP originates directly from the vertebra, intervertebral septa and LS disks. Kapanji has shown that when the IP fires but the femur is fixed, the LS spine will rotate. This is type of motion very detrimental to intervertebral disks over time.

    4. When sagittal plane foot restrictions exist, hip extension is limited during single support phase. Lack of full hip extension during single support limits the amount of motion available for pre-swing. The less pre-swing motion...the more the IP has to work to achieve normal swing phase.

    Hope that this answers your question.

  25. Dave:

    I think what Howard is saying here (and I'm sure Howard will correct me if I'm wrong), is that the lack of hallux dorsiflexion will decrease the magnitude of hip extension motion in late stance phase which will, in turn, decrease the elastic strain energy storage in the soft tissue structures anterior to the hip joint that help accelerate hip flexion in terminal double support. Because of the reduction in release of hip flexion elastic strain energy during terminal double support (i.e. due to the reduction in hip extension), the iliopsoas complex, to accelerate hip flexion to a given hip flexion angular velocity, will need to have increased contractile activity versus when normal hallux dorsiflexion occurs (i.e. when hip flexion is initially accelerated by hip flexion elastic strain energy).

    Certainly this is a theoretically plausible mechanism in the production of low back pain and even though I don't think it is the whole story, may be an important factor in the clinical improvement in low back pain that many of us see with custom foot orthoses in our patients.
  26. efuller

    efuller MVP

    Winters data on ankle push and hip pull are not consistent with the idea of gait being hard wired. Winter showed that there was a trade off between ankle push and hip pull to add energy to the pre swing leg. That is if you had ankle push, you don't need hip pull. Winter showed that the trade off varied across subjects and within subjects on different days.


  27. Dananberg

    Dananberg Active Member


    ......and Herman, etal in "Neural Control of Locomotion" showed that swing phase IS hard wired. Considering that infants exhibit the "kick phase reflex" when held by their arms, and obviously long before they learn to walk, seems consistent with Herman's findings.

    Also, with Winter's "pushoff, pulloff" concept, it doesn't mean that the iliopsoas isn't firing...it just means that it isn't only the psoas that can be active. The principle here is that the iliopsoas will be consistently active at the time toeoff occurs. The effet that it has, or the stress/strain it can create, is quite variable and dependent on multiple factors, one of which is the position of the limb at the time pre-swing phase begins.

  28. Graham

    Graham RIP


    As the leg extends through the hip the hamstrings and calf muscle stretch with an excentric muscle contraction, therfore storing energy. As soon as heel lift is initiated by a small concentric contaction of the calf the stored energy is released, including that of the spinal engine. The leg is accelerated forward. AS it passes under the trunk the illiopsoas fires to perpetuate the motion on to heel strike.

    If the leg fails to full extend there is not enough excentric energy stored therefore the illiopsoas has to activate sooner and for longer to drag the leg forward. When this muscle is over worked concentrically it gets stronger but shorter, as does the calf muscle, being used to create the abductory twist required to move the COP back to the swing leg, and the hams shorten as they never reach full extension.


  29. Graham:

    Sounds like a bunch of theoretical musings to me, Graham. Do you have any references to back up of your theoretical guesses??:rolleyes:
    Been waiting for this type of posting from you for a few months now.:drinks
  30. Graham

    Graham RIP


    If you can't beat them, join them (you)! :welcome:

  31. Graham

    Graham RIP


    31. Winter, D.A. (1995). Human balance and posture control during standing and walking. Gait & Posture. Vol.3. No.4. Dec.

    32. Winter, D.A. and Scott, S. (1991). Technique for interpretation of electrodynography for concentric contractions in gait. J. Electromyogr. Kinesiol. Vol.1. pp 263.

    33. Sutherland, D.H., Cooper, L. and Daniel, D. (1980). The role of the ankle plantar flexors in normal walking. The J. of Joint and Bone Surgery. Vol.62-A. No.3. April. pp354-363.

    34. Murray, M.P., Guten, G.N., Sepic, S.B., Gardner, G.M. and Baldwin, J.M. (1978). Function of the triceps surae during gait. J. of Bone and Joint Surgery. Vol. 60-A. No.4. June. pp 473-476.

    35. Simon, S.R., Mann, R.A., Hagy, J.L. and Larsen, L.J. (1978). Role of the posterior calf muscles in normal gait. The J.of Joint and Bone Surgery. Vol.60-A. No.4. June. pp 465-472.

    36. Brandell, B.R. (1977). Functional Roles of the Calf and Vastus Muscles in Locomotion. Am.J.Phys. Med. 56: pp 59-74.

    37.Sutherland, D.H. (1966). An electromyographic study of the plantar flexors of the ankle in normal walking on the level. J. of Bone and Joint Srgery. Vol.48-A. Jan. pp66-71.

    38. Close, J.R. and Todd, F.N. (1959). The Phasic Activity of Muscles of the Lower Extremity and the Effects of Tendon Transfer. J. Bone and Joint Surg. 41-A: pp 189-208, March.

    39. Eberhart, H.D., Inman, V.T., Saunders, J.B., Levens, A.S., Bresler, B. And McCowam, T.D. (1947). Fundamental studies of human locomotion and other information relating to the design of artificial limbs. A report to the National Research Council, Committee on Artificial Limbs. Berkley, University of California.
  32. David Smith

    David Smith Well-Known Member


    I asked for a reference because you said earlier you didn't want to go around this subject again and I didn't want to appear to be pushing you to do that. However thanks for your reply. I have some ideas to put forward and questions to ask but do you still want to go any further?

    All the best Dave
  33. Graham,
    Your description of muscle shortening fits with that of Janda's (1979), but what good quality clinical evidence is there that supports this or Gracovetsky's (1988) spinal engine theory? I should be grateful if you could point me in the direction of some refs for these please.
  34. Dananberg

    Dananberg Active Member


    I would be glad to continue a discussion on gait and lower back pain but, and with all due respect to Eric, won't go round and round beating a dead horse. So, if we try to keep the discussion to the overall concept and not confuse the issue by knit picking about exceptions that miss the entire point ...I am pleased to continue. I am open to sincere critique, as prior on-line discussions have only improved my understanding of gait and chronic postural pain. Eric, Kevin and I have gone around for years on this subject, and I have truly enjoyed the experience and benefited in many ways. As I get older, however, I have less desire to argue, and a far greater need to teach. With all that in mind, ask away.

    For a recent reference, go to the www.vasylimedical.com website for a series of articles I have authored on this subject. (I am a paid consultant to Vasyli.)

  35. Smilingtoes

    Smilingtoes Active Member

    What is the accepted necessary range of motion for the 1st metatarsal phalangeal joint?

    I work on the principle of 65 to 85 degrees being necessary for forward propulsion.

    I’m unsure of the validity of this.

    Does Hallux Limitus label all whose 1st metatarsal phalangeal joint does not extend more than 65 degree’s?

    Any help regarding this definition would be appreciated as I plane to investigate the relationship Hallux Limitus has on frontal plane biomechanics in a state of the art lab environment.
  36. Hallux limitus is seen as the inability to dorsiflex the first metatarsophalangeal joint past 65 degrees (this is agreed by many authors HJ Dananberg, JJ Drago, JE Licchniak) as at least 65 degrees of dorsiflexion is needed for normal ambulation to occur.

    There are various degrees of hallux limitus - functional hallux limitus is the inability of the first MPJ to dorsiflex on functional movement (weight bearing) whilst being able to dorsiflex past 65 passively.

    Hallux rigidus is seen as the end stage of hallux rigidus and there is a generic grading system often used to classify the stages from limitus to rigidus:
    Grade 1 - limited motion of the 1st MPJ, mild pain no significant degenerative joint disease (DJD)
    Grade 2 - as above with increased pain and early DJD and small osteophytic growth
    Grade 3 - as above with increased DJD and osteophytic growth
    Grade 4 - Joint ankylosis end stage DJD

    hope this helps


    ps a couple of good papers to look at are Halstead Turner and Redmond 2005 - the relationship between hallux dorsiflexion and ankle joint complex frontal plane kinematics.


    Effects of Rearfoot-Controlling Orthotic Treatment on Dorsiflexion of the Hallux in Feet with Abnormal Subtalar Pronation. Munuera, Domínguez, Palomo, and Lafuente. 2008
  37. Smilingtoes

    Smilingtoes Active Member

    :drinksThanks John a great help, I'll have a look at these references.
  38. Sorry simon, miss read the quote first time.

    Dananbergs study was excluded as it wasnt an RCT as was sobel 2001 and wosk 1985 did not have randomisation.

    using insoles as a preventative doesnt seem very logical anyway, they may be able to affect the symptoms by addressing the casue. but i dont see the logic in using them before there is dysfunction. so i do agree with there results.
  39. Phil Wells

    Phil Wells Active Member


    I just want to throw something at you re the theoretical 65 degree motion.
    If a patient has an abducted gait, do they still need this range?
    Check out patients with this gait style and they have no symptoms of FnHL but have callus on the medial border of the hallux and often dorsal osteophytes over the 1st ray/medial cuneiform.

    The point I would make is that FnHL can be part of a sagittal plane dysfunction but not always part of the pathology - check out Nesters work on Midtarsal joint axes and you can see what can happen prior to hallux loading.
    Anecdotally I regularly see gait styles with a delayed heel lift and resultant midtarsal joint compensation that have a midtarsal joint that has a high degree of abduction non-weight bearing than other gait styles. These feet should have FnHL but seldom do.


  40. Graham

    Graham RIP


    Nope! I have none. Just some biomajic musing. I took a spoon full of kirbyism to try it. Tastes good initially but lacks something definate.


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