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Help and advice for hypermobile patient

Discussion in 'General Issues and Discussion Forum' started by mgates01, Oct 8, 2009.

  1. mgates01

    mgates01 Active Member

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    I'd greatly appreciate any advice on a recent patient .
    This young girl (15yrs) was referred to me by a physio for "retracted toes"
    The problem is fairly self evident when you see the photos. This young girl is hypermobile. I can passively straighten her toes while she is standing but within 2,3 steps the lesser toes revert back to the position you see in the photo.
    Her stance as you may be able to make out is is slightly supinated.
    I have referred her to a paediatrician who I believe is doing some neurological and genetic investigations.
    A local orthopaedic surgeon has also assessed her and he referred her to another orthopaedic surgeon out of this area who is a foot and ankle specialist. It was difficult to actually know what this surgeon is planning as the young girl and her father were rather overwhelmed by the consultation and did not really understand what he was suggesting. From what I can gleam he is planning a tendon transfer (flexors to extensors), of all lesser toes??

    When I ask this young girl to actively extend her toes there is no response - it's as if someone has cut the EDL. I'm assumimg with her hypermobility that the EDL has become so stretched as to be totally ineffective.
    Apart from the problem with her toes her feet actually give her surprisingly few problems, although she does admit to some ankle instability.
    I'm wondering what kind of advice I should be giving this young girl regarding her surgical options, and if there is anything I can do orthotically, (is that a word??), to make a difference. I'm seeing her again soon and I'm considering orthoses with a deep heel cup, high medial and lateral flanges to help stabilise the ankle joint /subtalar joint and a lateral skive to increase pronatory moments at STJ.
    I was wondering if there is any kind of forefoot extension that I might add to help resist the toes tendancy to retract or is this just gone too far.
    From what she tells me the toes have always taken on a "funny" shape it's only in the last 9-12 months that this has deteriorated into the problem she now presents with.
    Any help would be appreciated

    Attached Files:

  2. hi Michael,

    Where to start so this makes sense.

    1st I suggest you look up a thread called reverse windlass effect. I´m still working out how to link from PA but a search will find it.

    also read the articles below

    When the patient comes back look at how tight the plantarfascia is during weightbearing ie midstance .

    I could be that a tight plantarfascia is not allowing the toes to extend ie no reverse windlass.

    So as you stated she is supinated during gait, so stj axis is laterally deviated which means that you will want to cause the stj to pronate through a lateral shrive again as you stated which with ground reaction will cause an extension of the toes as the plantar fascia lengthens.

    If you find this is the case you will need alot of physical type treatment as well to strenghten the peroneal muscles and plantarfascia massage .

    Of course is could all by a neurological complaint which you mentioned. Hope that the info and articles help.

    Attached Files:

  3. Hi Michael
    What if you put a plantar metatarsal pad, to try and straingthen out the toes. To exercise and strengthen the flexor and extensor muscles. Also by maybe elevating the metatarsals you will be able to bring the toes into ground contact and also redistribute the weight.
    What do you think? :confused: This is such an interesting case. Please keep us updated.
  4. david3679

    david3679 Active Member

    Hi Michael

    Could be that the young lady has a forefoot equinas. That would give her very tight posterior groups and plantar structures. That would also dictate that the set up of agonists and antagonists is a bit Knackered. If posterior and long muscle groups are tight due to f/f equinas then of course toes will take the hammer and also the the forefoot is compensating then becoming Hypermobile.

    I would ask for more info as your info is great about the problem but not the cause of it ( for example no weightbearing findings)
    Planal dominance, joint evaluation, muscle testing, shoe wear. etc

    Cheers Dave
  5. scsanki

    scsanki Member

    it appears as though the entire lateral column has collapsed, so the addition of some support beneath the cuboid would be advantageous.

    if the foot was supported laterally, it may add stability, thus reducing the need for the excessive flexor stabilisation.

    soft tissue therapy to restrengthen the weak extensors would be necessary too, as they probably havnt been used in a long time
  6. Mark Egan

    Mark Egan Active Member

    Hi Michael,

    A couple of questions -

    1. Why would this be getting worse suddenly ? triggers i.e. shoes activity other changes in mechanical functioning?

    2. Did you try some taping and padding on the feet ?

  7. Sammo

    Sammo Active Member

    The photo's hint towards a tibial varum, What is going on further up the leg? What is STJ RoM like? what is the view from the back and how does she look when she is walking? Ankle RoM?

    One theory could be that (off I go....) the lesser toes are clawing to try and stabilise the lateral column of the foot and provide some pronatory moments about the STJ (to reduce lateral instability) by plantarflexing the lesser toes and lateral aspect of the forefoot? (Does that sound plausible or am I off in my own little mental hinterland?)

    Interesting case...
  8. scsanki

    scsanki Member

    sounds exactly like what i was thinkin!
    so, we are in your mental hinterland toghether>:empathy:
  9. mgates01

    mgates01 Active Member

    Thank you all for your responses - most seem to confirm what I was planning orthotically. I'm seeing this young girl next week or so I'll try and answer some of your queries after I've seen her. I'll also try and take some more pics.
    Those questions that I can answer now,
    "why would this be getting worse" - I'm not entirely sure if the problems has worsened. She has been seeing the physio for about a year before she was referred to me and her parents weren't aware of the extent of the problem as she didn't complain (she's a very incomplaining type of girl).
    She has other joint pains consistent with hypermobility, (sorry I thought I had included this in the original post), shoulder, wrist, hip.
    In terms of her joints - movements were smooth, unrestricted and the range of motion was large (again consistent with hypermobility). There didn't appear to be excessive shoe wear (this young girl wears trainers with velcro fastenings), and her foot wear has been consistent for a number of years.
    Another colleague tried otoform splints (these just fell out) and I have tried a type of prop bulit into a slimflex insole - this has proved less than successful - although the young girl states it doesn't feel any different I'm seeing toe impressions on the plaztizote covering that might suggest some temporary straightening of the toes - maybe that's just wishful thinking on my part!!
    I haven't tried taping so that might be an option - though I have thought about producing some sort of modified budlin splint but I need to get my head around how that might look.
    thank you agin for all your ideas and I will certainly keep you updated
  10. Have you performed active resisted tests of EDL? Is this a cavus foot?
  11. mgates01

    mgates01 Active Member

    Hi Simon,
    there is zero response from EDL to resistance. Even when I ask her to passively extend her toes - nothing!!
    I wouldn't have described her foot as particularly cavoid.
    I think I'll try and take some more pics when I see her and maybe even a video if she grants me permission that might help people see this foot in action.
    I think maybe I'm not describing this foot very well.
    I might need help (admin) in downloading the video if I'm able to do one.
  12. efuller

    efuller MVP

    Some thoughts

    From looking at the picture you can see that she actively contracting the FHL muscle causing IPJ plantar flexion. (It's not the plantar fascia because it would tend to cause MPJ plantar flexion moment which would tend to cause IPjoint dorsiflexion moment.) From your description of being able to straighten the toes and then having them curl again it would indicate active contraction of the FDL muscle.

    From the work of Hicks the FDL is a supinator of the STJ as well as plantar flexor of the joints of the digits.

    Some questions. When she stands relaxed, can you see any tendons stick out. (You'd be surprised how many people think they are relaxed when you can see active contracture of the PT tendon.) What is her PT strength (is she usind FDL to compensate for a weak PT?

    What is her ant tib strength?

    The inability to actively contract her EDL could lead to unopposed flexor contracture and could cause the curling. However, it seems that there is a recent onset. Think neurological.

    A lot of surgery is based on little biomechanical thought. You look in the textbook and check of the lists and choose the surgery. If the problem is curling toes, then you straighten them. Perhaps fusion over tendon transfer. However, it would be important to figure out why EDL is not working before even thinking about surgery.

    It's hard to imagine anything under the toes keeping the toes straight. Toe loops (tubes?) to pull the tops of the toes down.

    Does anyone know of any longitudenal studies of hammertoes that track the amount of loss of motion over time. My sense is that things that stay contracted over time will lose range of motion.


  13. Sally Smillie

    Sally Smillie Active Member

    What is her ankle dosriflexion range? Of course, you need to rule out neuro possibilites but I've a had quite a few like this, and the toe position worsens after a peropd of growth as the posterior compartment becomes relatively tight and pulls digits into flexion.

    When testing, look at the toe flexion whilst ankle is in plantarflexion and how it changes as you move through plantagrade to dorsiflexion. If the digits become increasingly flexed as you move through the range, you have your answer. Gastroc (ie. posterior compartment) stretches with additional flexion applied to digits (felt tip pen under toes???)

    Good luck
  14. efuller

    efuller MVP

    Since the FHL muscle has significant lever arm at the ankle joint, as you move the ankle from dorsiflexion to plantar flexion everyone will be unable to plantar flex the hallux less with the ankle plantar flexed. This is caused by the physiologic fact that the muscle belly can only shorten a specific distance (tendon excursion). You can either use the tendon excursion to plantar flex the ankle or to plantar flex the toe but there is not enough excursion to do both.


  15. Sally Smillie

    Sally Smillie Active Member

    perhaps I wasn't clear enough. I meant a simple observation of the degree of flexion of the digits as you move the ankle through it's joint range. With normal muscle length the digits will maintain a neutral position from plantagrade up to end range dorsiflexion (which should be about 10-25 degrees), if observation of the digits reveals marked flexion as you move thorgh range, this indicates relative tightness of the musculature. Stretching is then in order.

    The key factor in this case is the fact that the patient is 15 and growing. This frequently occurs after a growth spurt, see previous posting.

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