Think about it intuitively - they apply a force of value x at night to attempt to straighten the deviated first MPJ. How many steps the next morning do you think it takes to match the value x and undo any benefit that might have been gained ---- let alone the concept of the ability to remold bone as you get older ...
The only evidence available for its use is in children where body weight (ie the day time deforming forces are lower than adults) and bone remodelling is more possible:
Having said that I have occasionally used them in patients with a chronic sort of "ache"/pain in the first MPJ ....
Tim did not do a study on night splints as far as I know. In his orthoses study in JBJS he referenced the above Groiso study. If he did write that they did nothing, I am not surprised for the reasons I said above.
Well back in the archives, Which (the consumer magazine) in the UK did a feature on "bunion straighteners" and reported comsumers found them of no practical worth. What was interesting was the pollees rarerly complained and subsequently (according to Which) the product kept selling.
What was implied was the consumers were too embarrassed (at making the purchase in the first place) and were more comfortable with forgetting the matter (to the extent of not even asking for their money back)
The origins of night splints came when toe traction (orthodigita) was very popular in the nineteen thirties (during the Depression) when surgery was less available and physical culture prevailed. There was greater emphasis on therapeutic exercise (both passive and active). Pull and
set approach of stretching and holding was supported by Wolf and Davis's observations on soft tissues and bone molding and so they were really trendy. Public Health promoted health for all and body culture determined idealised feet ( high arch, straight toes and no bunions). Much empahsis was placed on preparing the next generation to be ready for war.
Budin and co., recommended regimes of intrinsic foot muscle exercises (later promulgated in the UK by Lambrinudie) for children and this was the Genesis for foot health exercises. However as far as I am aware there is
no independent evidence to support with predictable outcomes,
no matter what interim benefits might acrue, such as inferred increased micro-circulation. Sensible shoes for children are introduced at this time and of course this was the era of the arch support. Heat treatments were also a vogue at this time.
All good ideas but little real significant evidence to support use other than anecdotal evidience.
British Journal of Podiatry November 2004 ; 7 (4): 101-105
Conservative treatment of juvenile hallux
valgus - A seven-year prospective study
Andrew J H Macfarlane, T E Kilmartin
Conclusion:
This study has demonstrated that night splints can, over an average of 3
years treatment, prevent the deterioration of juvenile hallux valgus and
subsequent development of associated deformities of the other digits. There
is clear justification for deferral of surgical reconstruction until
skeletal maturity when the outcomes of surgery are likely to be more
predictable. Further, night splint therapy should be considered as a first
line treatment for hallux valgus.
This pretty much supports and explains my clinical use and observations.
Firstly, thanks Simon for the update! Secondly, I have worked in Podiatric Surgery departments and tried night splints, the vast majority of people find them extremely uncomfortable to wear and usually end up taking them off.
:)
As you know, at the end of the day, the choice of surgical procedure to correct a hallux valgus will depend on the a variety of factors, and IM angle will be the main one most people cite. So if a night splint can decrease the amount of detrioration of the IM angle (was this looked at in the study?), then you might argue that a distal Austin/Chevron style procedure with soft tissue balance might be more likely, rather than more proximal procedures, which theoretically are slightly more technically difficult. I doubt the night splints have any effect of secondary lesser toe changes, which would be more likley to be affected by day time use of foot orthoses (I hope).
That being said, the operation time, postoperative recovery, costs and rehabilitation are all very similar, and the choice of procedure will be of little relevance in the grand scheme (even if the degree of deformity is greater).
Each to their own, but I would just let the thing take its course, and fix it when pain/deformity and age indicate the need for intervention.
"This study has demonstrated that night splints can, over an average of 3
years treatment, prevent the deterioration of juvenile hallux valgus and
subsequent development of associated deformities of the other digits."
Interested in your use of foot orthoses. Could you point to where these have been shown to reduce secondary digital deformites in HV?
Don't have the study in front of me so can't answer your question re: IM angle. Not my study, me just a message carrier.
You would know better than most that there is no evidence (that I know of) that foot orthoses can help lesser toe deformity in HV. Hence the post script "(I hope)", considering the lack of any other great options in these typically flexible, hypermobile feet. Despite Kilmartin's other paper, I still live in the vain hope that they do something to affect weight-bearing forces during the day...just look at the navicular-cuneiform faulting on most of them! An orthotic has to do something to help that medial column instablity? I hope some cleverpants like yourself can prove that one day.
Didn't read the comment on lesser digits. I wonder if the night splints only helped the transverse plane drift of the 2nd or lesser toes, or if there was any effect in the sagittal plane and less hammertoe development?
Has anyone had any experiance of using hallufix Day and night splints? They're a polyprop splint with an articulation (saggital only) which claim to be wearable in shoes. Website at www.hallufix.de.
I have used the Gel & Leather Bunion Night Splint from Dr. Jill's Foot Pads with great success. It has a very comfortable silicone gel section on the area that gets placed right next to the foot and a metal section covered with leather to hold the Hallux straight. Patient compliance was great and even some of my patients felt it was so comfortable they wore it in their shoes during the day as well as the night.
Jill Scheur,DPM
Williamsville, NY Jill4feet@aol.com
In addition to the glowing endorsement you give above for the bunion splint, you are also the owner of the company http://www.drjillsfootpads.com/page5.html
and you just thought that a little free advertising would be in order??
Congratulations, you have now joined the company of Ed Glaser and Brian Rothbart on Podiatry Arena.
I've really taken to the opportunistic product plugging on this site and think we are missing a trick here. Perhaps, we could get Noel Edmonds in and do a multicoloured swap shop thing (not only does this statement age me, it also shows just how parochial I am- those of you not familiar can google it I'm sure)
I've got a pair of used AOL's that I'd like to swap for a Jensen Interceptor. Any takers?
What scares me is that if you ARE going to do a shameless plug for your own product, Dr Jills foot pads, and pretend to be a satisfied customer, why would you use an avater which says Dr Jills foot pads and give yourself the profile title of DR JILL!?!?!? Did'nt really think this one through did she?
I am a little dubious of Kilmartins paper on juvenile HAV treatment by orthoses. He did not allow the first ray to plantarflex. This would likely cause jamming and subluxation of the 1st MTPJ. As a plantar or dorsiflexed first ray would seem to contribute to the pathology (as indeed mentined by Kilmartin in an earlier paper), surley an orthoses with a first ray cut out would benefit this condition.
We don't know if that was the case or not. Its widely suggested that is the case, but we just do not know. Those who do not like the outcomes of the Kilmartin et al study like to claim that, but I would like to know how they know it is the case. Kilmartin never published any work on how the foot orthoses he used affected first ray function (that does not mean they didn't).
We don't know if that is the case or not. Theoretically it could be the case, but no one has actually done any outcome work to show it.
Hi Paul
Could you please describe in a little more detail how the exercise is performed.
Are there any joints you mobilise prior to this exercise program.
Thanks in advance
Iona
I get the patient to stand on a phone book with both feet while standing at the sink
2. stand the affected foot as in standing on tip toes
3. get them to move to the affected side and lift the non affected leg off the phone book, now taking body weight on the toes
4.slowly let the foot relax over 4 seconds. At 4 seconds the heel should be on the ground.
5. start all over again.
Basically you are performing an isokinetic eccentric lengthening exercise.
Both feet flat on phone book. take affected foot off the phone book, get them to plantar flex and then take their weight on this foot when it is on the floor.
I have HAV's on both feet, as does my mum and nan did too. I also have no trouble activating the abductor hallucis muscle, in fact it is quite defined!! only a sample size of 1, me, but just thought you might be interested in this.
As for the night splints, I find some patients love them and wear them religiously, yet others simply cannot bear to wear them for longer than a few minutes. i have also found that for the harder plastic splints, sometimes a small otoform pad between the splint and the 2nd digit can alleviate some of the discomfort. I have also just given a patient one of the softer splints used for post-surgical alignment which appreared to have decent traction/support and be a lot more comfortable for the patient to wear. There is no research/evidence behind any of my thoughts, just my 2c. I also must stress that I always explain to the patient that the night splint is not a cure, it just may help with pain/aches associated with the HAV.
Paul
ha ha mate, its not really that I challenge what is written, Im just too busy to read that which is written, so if I want to know if something works, I generally try it (within reason of course). That and the fact that there is a lot of research that "sits on the fence" so to speak, with no real outcomes either way, which I find really frustrating sometimes.
As for the activation, I cant actually say that they are endurance muscles, my experience usually involved thinking hmm wonder if I can work this muscle?? I have noticed however, that direct pressure with my finger up near the muscle belly will abduct the hallux like a muscle contraction.
Not sure of the relevance, but pretty interesting to see the hallux "straighten" when I do it...
Paul
what i meant mate, was I was just looking at my feet one day and wondered if I could contract the muscle. Like trying to move single toes etc. This was way back in high school biology class, not final year Podiatry or anything. And by saying it wasnt exactly an endurance muscle, I meant after five or so contractons, you can feel it getting tired is all. By palpation, the muscle wasnt contracting, it was relaxed and the palpation produced the same results as a contraction.
Interesting about you saying how actively involved the muscle is during walking too. During uni life, I used to walk approx 8k a day and the muscle was actually quite big and solid.
Sorry for the confusion mate