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Hallux abducto valgus and orthotics in children

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Holapod, Nov 15, 2017.

  1. Holapod

    Holapod Member

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    hi there, I have recently had two adolescent females present to the clinic both with bilateral HAV.

    The first patient had foot pain and so I prescribed custom orthotics and in conjunction with a prescribed exercise program she has a good outcome in terms of reduction of pain

    The second patient has no others oot pain but bilateral HAV. With pain due to bursa irritation. I have discussed all padding, strapping, footwear etc

    I really struggled in terms of what biomechanic variations I should be looking for that may be contributing to the HAV and what evidence do I have in terms of orthotic therapy and the formation of HAV. I'm not wanting to prescribe orthotics for prevention unless it's based on some sound information. Can anyone please point me in the right direction??

  2. bobtheweazel

    bobtheweazel Member

    I usually consider for the most part that anything that leads to elevation/dorsiflexion of the 1st ray could lead to hallux limitus and/or hallux valgus. If the 1st ray is elevated/dorsiflexed then it cannot plantarflex to help resupinate the foot and the prolonged pronation I then assume leads to a more abducted forefoot with the adductor hallucis being better positioned to overpower the abductor hallucis. And the usual rolling off of the medial side of the hallux in response I assume also doesn't help matters. I'll list some examples of mechanisms I can think of right now but there are probably some more as well.

    Equinus - Need more sagittal plane motion from somewhere so there's a rearfoot pronation that allows the talonavicular joint to extend sagittaly to give some of that motion but as a result the 1st ray is relatively elevated.

    Some Cases of Forefoot Varus, Lateral Column Anterior Cavus, 1st Ray Elevatus - The 1st ray is already elevated relative to the lateral side of the foot in this case. Obviously to get the medial forefoot down will probably require some degree rearfoot pronation which would have to persist long into stance. Also the center of mass will be more medially located over these feet so there are a couple of things working to prevent the 1st ray from being able to adequately plantarflex. I assume that the less rigid the deformity the less of a factor it would actually be.

    Some Cases of Forefoot Valgus, Medial Column Anterior Cavus, 1st Ray Equinus - If its the case that since the 1st ray is already starting in a relatively declinated position that it ends up being subjected to increased ground reaction dorsiflexory force throughout stance then that may be a factor in preventing adequate plantarflexion of the 1st ray later in stance. I assume that the more rigid the deformity the less of a factor it would actually be.

    Hypermobile/Less Stiff 1st Ray
    - Whatever you wanna call it, even if the 1st metatarsal head is in relatively the same plane as the others and that plane is relatively parallel to the supporting surface to begin with, if it takes relatively less dorsiflexory force to dorsiflex the 1st ray then the it would be more difficult to plantarflex when loaded later in stance and so would stay relatively more dorsiflexed than it should.

    Medially Deviated STJ Axis
    - If the STJ axis is deviated medially enough then the area of the plantar foot contributing a pronatory torque around the STJ would easily overpower any attempts by the fibularis longus to plantarflex the 1st ray.

    Orthoses - I'm not sure you could really say that there is one specific type of device to prevent or treat all hallux valgus, though you could probably generalize that you want would want to facilitate sagittal plane motion so that you don't need to compensate at the talonavicular joint (e.g., heel lift for equinus), prevent rearfoot pronation (e.g., medial forefoot wedge for forefoot varus, medial heel skive for medially deviated STJ axis, etc.), reduce dorsiflexory forces on the 1st ray and/or allow room for the 1st ray to plantarflex (e.g., lateral forefoot wedge for forefoot valgus, plantarflex the more mobile 1st ray while casting to leave room for it to plantarflex, etc.).

    I don't really have studies to back any of this up right now. But I did stay at a Holiday Inn Express last night.
  3. Holapod

    Holapod Member

    thanks for taking the time to reply bob ill go over these and have a good look

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