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Hallux valgus in forefoot valgus

Discussion in 'Biomechanics, Sports and Foot orthoses' started by fabio.alberzoni, Jan 2, 2013.

  1. fabio.alberzoni

    fabio.alberzoni Active Member


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    I had a female patient of 81 year which has an hallux valgus with an important frontal deformity causing traumas of hallux's nail.

    GENERAL: height: 1,61 meters
    - weight: 78 Kg

    CLINICAL: anterior pes cavus bilateral
    - tight triceps (+2° of foot dorsiflexion when the knee is extended)
    - forefoot valgus 8°-9° bilateral
    - STJ not rigid and with good ROM
    - genu recurvatum
    - Hallux Valgus with transverse plane angle of about 40°
    -hammer toes

    SKIN: Hyperkeratosis under first and fifth metatarsal heads and on the plantar/lateral side of the calcaneus.

    STATIC: Inverted hell - Coleman test: the heel turn vertical

    DINAMIC: inverted heel in the whole gait - early heel lift - lateral instability - difficulties charging the forefoot to avoid pain - phisiological extrarotation (10-15°)



    THE ANSWERS:

    1. I've always studied that pronation, high hells, footwear ect ect grew up the risk of hallux valgus.... Now, WHICH IS THE BIOMECHANICAL EXPLANATION OF SUCH A PATIENT? IN PARTICULAR OF A EVERTED NAIL'S ANGLE TO THE GROUND OF ALMOST 50° IN WEIGHTBEARING?:bang:

    2. TREATMENT advices ( not surgery)?


    Anyway happy new year to you all!...and thanks!

    fabio
     
  2. drsarbes

    drsarbes Well-Known Member

    I would assume that if you had xrayed this patient you would have seen a metatarsus adductus deformity and a 1-2 intermetatarsal angle smaller then you would expect.

    I have found that FF valgus patient do - in fact - develop hallux valgus with the decades of living on a planet with gravity pushing the first met slightly dorsally and medially. With the ensuing tightness in the AT and resulting decreased dorsiflexion at the ankle the extremity is externally rotated at push off and forcing the hallux in an even more abductovalgus direction.

    It still amazes me how bad, clinically, these look and how small the intermetatarsal angle is on xray.


    Steve
     
  3. fabio.alberzoni

    fabio.alberzoni Active Member

    awesome clinic...unfortunatly I'm waiting to see the xrays....
    during the clinic examination I didn't note a metatarsus adductus..probably was my fault!

    It's probably as you suggested! thanks!

    fabio:good:
     
  4. efuller

    efuller MVP

    When discussing treatment it is always good to know what are the patients expectations and problems. Is the problem medial bump pain at the 1st metatarsal head or is it pain with compression and range of motion of the joint. Or is it something else.

    Explanation of why a patient with lateral instability (too much supination) can have a pronation related problem (HAV). A laterally deviated STJ axis can cause lateral instability or a tendency for the STJ to supinate. To prevent the STJ supination the peroneal msucles will contract. I some people you can see that the tendon is tight constantly. The peroneal tendons create the pronation moment that causes the pronation related problems. Your results in the Coleman Block test really make me think this is what this patient has. Often with these feet you will see late stance phase pronation in gait. The pronation will occur around the time of heel lift. If you look at the impression in the shoe you may see evidence of high forces under the first metatarsal head and hallux.

    The treatment for the laterally positioned STJ axis is to increase pronation moment. This can be done in either the heel or forefoot or both. You have a longer lever arm at the forefoot. So, either a rearfoot or forefoot valgus wedge can be used to increase pronation moment from the ground. You may want to add a valgus extension out under the metatarsal heads as well as you may want this effect after heel off.

    Eric
     
  5. fabio.alberzoni

    fabio.alberzoni Active Member

    the problem is " traumas of hallux's nail" with associated pain caused by the clash between nail and toe.

    She already dress her foor orthosis, not mine, with a cut out of first and fifth metatarsal heads and a calcaneus lateral wedge.

    fabio
     
  6. efuller

    efuller MVP

    I get it now, the question is why does the toe rotate in the frontal plane. I'll bet the answer is force couples, but I'll have to think about which forces. As for correcting the deformity, I don't have much help for you there.

    Eric
     
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