Inverted wedge device and Abductor Hallucis pain

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I am posting this thread in the hope someone can provide a logical explanation and solution.
I treated an elite 3000m runner approximately 6 months ago for MTSS. He was training 5 times a week mixing 1 long run with 2 or 3 interval/speed sessions and competition once per week. He was predominently a midfoot to forefoot runnner and was training in brooks trance and racing in asics DS racers, he had a mild soft tissue equinus and RCSP of approx 7 degrees everted. Jacks test indicated poor windlass function, Functional hallux limitus. forefoot to rearfoot mechanics were normal. Slight forefoot abduction in RCSP
Treatement involved activity modification, taping (modified tib post taping) ice, massage and stretching. Initial results very positive so a flexible poly inverted wedge orthotic of 6 degrees inverted was prescribed with soft top cover and 3 mm heel raise. review at 4 weeks and all symptoms had resolved and the patient was training and competing pain free.

I reviewed him 6 months later where he stated a 100% resolve of the MTSS however he had started to develop abductor hallucis cramping during running. This was followed by significant pain (only with palption and not affecting normal activity) up to a week after strenuous running. It wasn't bothering him as much as it was just annoying and was the orthotic contributing to his discomfort. This coinicided with state competition and an increase in workload and i passed it off as overuse and to return if the problem didnt resolve with a reduction in workload.

Havent heard from my orignial patient but I had another recreational runner this week with the exact same symptomology following 3 months of inverted wedge orthoses. (Also functional hallux limitus)

Am I missing something here? Is there a significant biomechanical factor in play that I have missed? I was considering doing a first ray cut out to midshaft 1st met but only really doing this to try and improve windlass which already appears to be functioning fine. Orthotic contour is good and there is no overhang causing direct irritation of the belly of AH

Any thoughts?

 

Trigger point?

 

Does he race & /or speed sessions in these orthoses?
When doesn't he wear them?

How specific can he be with verbalising contributing factors preceeding / during pain?

Is the increased propulsive phase (FF / 1st ray loading) during faster work result in xs soft-tissue compression - is the shell flexible enough medially??

Try a Prothotic Wedge with large 1st Ray cut-outs up to the Navicular as an alternative for fast track-work and continue with Wedge for longer runs & warm-up/down (depending upon session type) - you will need to break this down to basics.

Cheers,

Paul Dowie

 

Hi (what is your name?)

Have you ruled out possible neurological causes? Were you able to elicit a (+) tinels sign in your follow-up assessment? Is there any other sensations the pt feels in addition to the cramping? Are his symptoms occuring in one foot or both?

Have you conducted a running assessment with and without the orthotics? Windlass function isn't generally considered to be as important during running.

There might still be excessive pronation moments occuring while he is running, which might be causing an excesive tensile force in the abductor hallucis muscle. Have you conisdered experimenting with 2 degree FF Varus extension? (Just a thought...)

Regards,

Dan

 

Anything that inverts the hindfoot significantly (in this case the orthosis) creates an "extrinsic" met primus elevatus. I saw this again today in a patient with an old compund tib/fib # with damage to the tibial nerve. The 1st metatarsal is dorsiflexed relative to its normal position and in order for the medial column to reach the ground the hallux needs to plantarflex. Usually the short flexor does the majority of this work (as in true hallux limitus/hallux equinus), but it is not unusual for the abductor hallucis to contribute significantly in a runner. Remember "too much varus is BAD". Feet cope better with more valgus than varus at the hindfoot. Thats why a triple arthrodesis is always set in a few degrees of hindfoot valgus, rather than neutral or slight varus.

Reduce the hindfoot inversion, concentrate the apex (ie moment of force) of the orthosis at the TN/NC joints (where PT inserts, not the STJ), and watch the abductor hallucis settle.

LL

 

Thanks for all your quick responses I appreciate them all and it gets my thinking reading through all of them.

LL is making sense with regards to the presentation of the patient I saw. I guess if the first ray is being dorsiflesed by increased varus control it is going to place an increased tractional force on the abductor hallucis, but i thought I would have seen this in conjunction with plantar fascial strain along the medial slip and at insertion also.

There is no neurological symptoms present so I didnt percuss the nerves to check.
I will try reducing the varus control of the devices and add a larger first ray cut out as suggested.

Dan why isn't the windlass effect as important in running? I not sure I agree with that nor would all the shoe companies pushing their windlass promoting footwear. If a functional hallux limitus exists in a midfoot to forefoot runner I would assume this would greatly impact on the efficency of the propulsive phase.

Regards
Luke

 

Luke:

The mechanics of running is very different to walking. During running, less hallux dorsiflexion is required during the propulsive phase, because the movement is more rapid and the CoM is moving in a more upwards direction. However, during walking, the forces occurring beneath the hallux are more prolonged and the CoM is falling, which means more dorsiflexion is required. Just because your static WB test (i.e. Jacks Test) may have identified that the pt has a functional hallux limitus, does not necessarily mean that the pt has a functional hallux limuts (FnHL) during running. As a result, the biomechanics of the 1st MTPJ is very different in walking and running.

By the way, if he is a midfoot to forefoot striker, then how is a RF 6 degree varus wedge going to be effective? In this type of runner, i would be more inclined to prescribe an orthotic which has minimal medial arch expansion and a varus FF extension. I believe this would address his running style more appropriately. In addition, i would only instruct this pt to wear this device for running purposes only as it may initiate 1st MTPJ symptoms if he was to wear them during walking. On the contrary, if he was a rearfoot to forefoot striker, then i believe a varus RF wedge would have more of an effect.

Regards,

Dan

 

Luke:

Do you only perform neurological assessments based on your pts subjective history? Just because his "symptoms" might not suggest that there is neurological involvement does not mean you should exclude it all together. How do you know for sure if you haven’t checked? The pts symptoms could be due to a compression on the posterior tibial nerve. This can often be overlooked.

Regards,

Dan

 

I used to get cramps in my abductor hallucis back when I could play basketball for 2 hours striaght. My foot would get very high medial forefoot loads as evidenced by shoe wear. A forefoot varus wedge could increase medial forefoot loads and cause increased use of the abductor hallucis to help stabilize the 1st ray.

Just a thought,

Eric

 

This is a classic case where the best case scenario will probably require multiple devices with different design features used for different sports / daily use.

Trial increased and decreased mid / FF pressure to determine most comfortable, and monitor.

Paul D :morning:

 

I struggled with this for some time after initially getting my orthoses and when I look at my abductor hallucis now, its a lot larger. Perhaps it is engaging this muscle more with his running due to better 1st MPJ function and it is going through a strengthening phase whilst also trying to maintain a high block of training?

Thoughts anyone?

 

Thanks for all of your input. A bit of a follow up. To answer some questions . . . .The reason I went with the rearfoot wedge was largely due to the fact that the guy was predominently a forefoot runner during the first 2000m of his event and as he would fatigue his mechanics would change dramatically adopting a more rearfoot-forefoot style with severe post tib strain and increased forefoot slap. This was largely the case in his training as well. I know this is largely probably a strengthening/ conditioning and running technique problem but the patient had trialled numerous programs to address this fatigue with little results hence the MTSS as a result. Ineveitably the wedge worked well for his presenting complaint and adressed his mechanics when he needed it ie when he fatigued 3/4 through training racing etc. I reviewed neurological symptoms last week as suggested by Dan and was unable to ellicit any symptomolgy. Have trailled a first ray cutout and decreased the varus angle in the most symptomatic foot will keep you posted

 

I understand the rationale of what you are saying, but just because they are a forefoot striker, does not mean there is no heel loading. Often track runners will midfoot strike and then touch the heel.
In addition to this, these athletes do a lot more than just run at speed- there are slower reps and walking around the track between reps etc. Sprinters, who may not touch the heel at all, can still benefit from rearfoot control for this reason.
Back to the original problem- if I saw this problem, I would be thinking possible 'over correction'... maybe the Abd Hall is trying to brace the hallux? Difficult to know with the limited info though. Are we talking about an athlete having the problem during track sessions only?? You say one side is worse- is it the inside or outside foot on the bend? This can provide some clues also...