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Admittedly, I don't have the greatest understanding when it comes to FF varus and FF supinatus, and how to tell the difference...

I have a 15yo boy with gross pronation in resting stance, due primarily to a very large FF varus/supinatus. However when I attempt to bring him into a neutral weightbearing STJ position - his 1st Ray and hallux lifts right off the ground.

My question is, how do I address this biomechanical problem with orthotic therapy? I don't want to elevate the 1st ray too much with my device and functionally compromise movement of the hallux at the MTP joint?

Thanks for any advice or tips.
Adam.

 

G'Day Adam,

I see a lot of patients with this forefoot deformity and manage them quite well with orthotic therapy. Being a 'Payneist' I'm not really convinced in the concept of a rigid forefoot varus, except in a secondary aquired situation. I find most of these are actually flexible, thus a supinatus. There are a few things I personally consider when addresing these cases:

1) Metatarsus primus elevatus- is this the primary pathology and is the whole foot therefore doing that horrible big flat thing where the talus is almost plantargrade to compensate? I've often found these to have a rigid 1st ray, especially in kids. Older people may have this aquired to to DJD in the proximal 1st ray.

2) Kirby STJ axis test- Remeber that funny test published by Kirby where you put the foot into NWB neutral and palpate out along the bottom of the foot to find whether the STJ long axis is either medially or laterally deviated? Do this! It will let you know where you need the correction. If the axis is significantly medially deviated, remember that the correction will have to come further back and be more agressive, say an inverted type device with correction under sustenaculm tali with an extrinsic EVA rearfoot post to elevate the proximal 1st ray sufficiently. A more normal axis will allow control over a larger area, to intrinsic posting up to the talonavicular joint may be more appropriate

3) hallux limitus and sagittalplane mechanics- More often than not, these patients will have a degree of hallux limitus, either functional or structural, due to the inverted forefoot position and elevation of the 1st ray. Remember that sagittal plane mechanics of the 1st ray are almost non existant also in these patients, so you need to account for these too. This usually leads me to make sure that there is adequate support promixally in the 1st ray, but almost nothng distally, even to a 1st ray cut out where necessary, to allow adequate distal plantarflexion of the 1st MTPJ and dorsiflexion of the hallux on the met head.

4) flexible- Most of these are flexible.. dont be scared to make a device and expect the foot to shape to it. Make the foot come to the ground, not the ground up to the foot (but only if it is flexible!!)

Hopefully this has helped a bit, any further quieries, just message me :eek:)

-Adrian

 

Ignore STJ neutral
Ignore forefoot to rearfoot relationship
Pay attention to what hurts and treat that

There are several threads on podiatry arena related to tissue stress approach to orthotic therapy. Read those

Sorry for the terse reply. I have been trying to convince people for the last 10 years that Neutral position and forefoot to rearfoot relationship is not the best way to understand and treat foot pathology. It has been discussed on this forum.

Happy hunting,
Eric

 

Hi Adrian,

you say at one point in your message that these feet are mostly flexible at the mid and forefoot (supinatus), then you go on to say that the first ray is almost immovable in the sagital plane...which is it?

confused :wacko: