Hallux limitus? curious conundrum - can anyone help?

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This week I saw a patient, it was the first time I had seen her. She reports an 8 year history of a painful hallux. She had developed a painful area under the IP joint and had developed an ipk. She was diagnosed at the time with hallux limitus and apparently had a sesamoid present plantar to the hallux ip joint. At separate occasions she had bonney-kessel and excision of sesamoid. Subsequently she had removal of fixation (threaded k wire).

Despite all this her foot has continued to be painful. She has now developed an altered gait, guarding the hallux. So she is now suffering lateral leg and foot pain probably due to her altered gait.

I do not have access to her original radiographs but recent radiographs show what appears to be a normal foot, Clinically, she has excellent ROM of her hallux, but very little active motion. In fact she generally has poor muscle power in this foot, however she has no sensory deficit and no tinels sign around tarsal tunnel.

so where do we go from here, I wonder if her original problem was the very heavy callus formation - maybe warty?? and that if this had been excised she may have not needed the other interventions. Or she could have some neuromuscular issue causing her odd gait.
I considered getting her f-scanned but her gait is so guarded currently that we might not learn very much.

tips gratefully received...

Simon

 

Re: curious conundrum - can anyone help?

Have you radiographically examined the lenght of her 1st metatarsal? Is it as long or longer than the second met? This could cause functional hallux limitus and would correlate with her symptoms and gait pattern. This conditions is also frequently associated with low back pain. You might also check for a metatarsus primus elevatus.

Respectfully,
Jeff

 

Re: curious conundrum - can anyone help?

Thanks for the response jeff, Yes her met parabola is pretty much normal, certainly 1st met not long. she doesnt seem to have any hyperextension at ip joint

Also she did not seem to be overly tight in calf complex. Also I had a look at the wear on inner of her runner, which showed pretty minimal wear under 1st met head, but a significant wear mark under her IPK. Most wear under lateral met heads.

cheers

s

 

Re: curious conundrum - can anyone help?

Simon,

I once had a strange case involving an employee of mine who had a painful IPK on her medial hallux. She had a good range of open chain dorsiflexion of her hallux but I happened to notice on exam that her IPJ was rigid. On further examination I attempted to mobilize the IPJ of her hallux by plantar flexing the distal phalanx. I was able restore a good range of motion with no significant pain to the patient. I casted her and made her orthoses and her IPK and pain went away. Problem is, I don't know if the mobilization or orthoses resolved it, but I suspect it was the mobilization. I doubt this is what she has, but it may be worth checking. I don't necessarily check motion of the IPJ but just happened to find it in this case.

How is her open chain range of plantar and dorsiflexion of the 1st ray? When you load and dorsiflex her lesser mets and plantarflex and dorsiflex the 1st met, do you get equal ranges of motion or does her range of dorsiflexion exceed her range of plantarflexion?

Other thoughts: possibly an uncompensated or partially compensated forefoot varus where she can't pronate enough to get her medial forefoot down prior to heel lift. You might see a spiral wear pattern on her shoe under the ball of the foot due to an abductory twist.

Respectfully,
Jeff

 

Whenever it appears that the 1st MTP joint/hallux, 1st met head are inverted (ie, avoided) during gait, I always examine for peroneus longus inhibition. This is the single most common finding I see in this foot type. Manipulation of the ankle will usually restore both ankle joint ROM as well as facilitate the peroneus longus. If this is her issue, then the outcome should show some immediate improvement, although resolution takes about one month/year of disability. Foot orthotics which allow for 1st ray plantarflexion (ie 1st ray c/o) will also help this type of problem. I will also add a forefoot extension of PPT (poron), with a kinetic wedge type depression sub 1st met head.

If you need information on the manipulation, go to www.vasylimedical.com and search resources section. (I am a paid consultant to Vasyli.)

Howard

 

Re: curious conundrum - can anyone help?

Jeff;
can you email me I wanted to get some information from you that we talked about in January. bwilliams@breakthroughpodatry.com
thanks
Bruce

 

Many thanks for your input Howard, I'll look at these areas when she returns to my office.