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Is functional hallux limitus due to a problem at the retrotalar pulley?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, May 19, 2010.

  1. NewsBot

    NewsBot The Admin that posts the news.


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    Functional hallux limitus or rigidus caused by a tenodesis effect at the retrotalar pulley: description of the functional stretch test and the simple hoover cord maneuver that releases this tenodesis.
    Vallotton J, Echeverri S, Dobbelaere-Nicolas V.
    J Am Podiatr Med Assoc. 2010 May-Jun;100(3):220-9.
  2. Admin2

    Admin2 Administrator Staff Member

  3. full paper- anyone?
  4. Griff

    Griff Moderator


    I've had to email it to you - for some reason it won't let me upload it here

  5. CamWhite

    CamWhite Active Member

    Functional hallux limitus is a loss of metatarsophalangeal joint extension during the second half of the single-support phase, when the weightbearing foot is in maximal dorsiflexion. Functionally, it constitutes a sagittal plane blockade during gait. As a result, the mechanical support and stability mechanisms of the foot are disrupted, with important consequences during gait. Functional hallux limitus is a frequent, though relatively unknown condition that clinicians may overlook when examining patients with complaints that are not limited to their feet, for they can also present other symptoms such as hip, knee and lower-back pain. The purpose of this article is to present a critical review of the literature on functional hallux limitus and to explain a previously described and simple diagnostic test (flexor hallucis longus stretch test) and a physiotherapeutic manipulation (the Hoover cord maneuver) that recovers the dorsiflexion of the hallux releasing the tenodesis effect at the retrotalar pulley, which according to our clinical experience is the main cause of functional hallux limitus. The latter, to the best of our knowledge, has never been described before.

    A couple of questions for the experts on this forum:

    1. In your experience, how prevalent is fnHL in your patients?
    2. I am not familiar with the Hoover cord maneuver. When I researched this, I got several vacuum cleaner demonstrations.
    3. Does the following video demonstrate an effective test for functional hallux limitus?

    I want to be clear that I am not promoting or endorsing the product in the video. I know that several others have developed products that claim to be beneficial for overcoming functional hallux limitus (Dananberg, Vasyli, etc.). I also want to disclaim that we, as a shoe store never diagnose anything.

    My question is: Is the test in the video an effective test to assess locking of the big-toe-joint?
  6. efuller

    efuller MVP

    And just how are these mechanisms disrupted?

    We are back to the chicken and egg argument about FnHL. Does the FnHL cause the arch collapse or does the arch collapse cause the FnHL? I would go with the latter in that when the arch collapses the plantar fascia and intrinsic muscles will become tighter and create the plantar flexion moment that prevents the hallux from dorsiflexing.

    Critical view of the literature???? It didn't include my paper.:mad: :rolleyes:

    Wow, are there some problems with their theory. First off their test dorsiflexes the first ray as well as the ankle so the reverse windlass would also be a plausible explanation. (In my opinion a much better explanation.) The second problem is their anatomical explanation of why the hallux motion is limited doesn't work. If I understand their explanation, they are saying that thick part of the tendon gets stuck at the back of the talus when the ankle dorsiflexes. This is backwards. If the tendon stays in the same place as the ankle dorsiflexes, the posterior process of the talus will rotate away from the thickened part of the tendon. (With ankle dorsiflexion, as the stuff anterior to the ankle joint rotates up, the stuff posterior to the ankle joint will rotate down.

    Haven't done the numbers, but would say common. It happens in my own foot.


  7. Here's a thought, we perform a Jack's test with foot standing on the stiff floor of our clinic, what would happen if we performed it with the foot standing on a more compliant block of foam or a tray of sand etc.. What influence does the density of the medium we perform this test on have on the outcome of the test. Cameron, if you are not diagnosing, why do you want to know about diagnostic tests? ;):D:eek:
  8. RobinP

    RobinP Well-Known Member


    Stop giving Cam a hard time - maybe he's just interested. I do not diagnose breast lumps but I still think that it is important that I know the examination technique!

  9. Yeah, maybe he's just interested or maybe he's out to make a dollar? Why should I care anyway? There seem to be more and more foot care specialists with less and less qualifications to be so. Just an observation. Perhaps it has not come to the Island of Man yet. "Both my wife and I have lived here all our lives. All our lives..."- Fast Show= obviously. Is it not with the tongue then? Do you like liver? Do you like liver and Bacon? Then come to the.... Great series of sketches.
  10. RobinP

    RobinP Well-Known Member

    I only said that to try and win the quote of the year contest

    I use the WEIGH technique - way hey hey hey!


    Christ, I'm turning into Benny Hill!
  11. dddderderdura, dddderderdura...
  12. CamWhite

    CamWhite Active Member

    I just enjoy learning. This forum makes us better shoe fitters.
  13. RobinP

    RobinP Well-Known Member

    Awesome - You don't know just how accurate that is in some cases!


    I think we might have wandered off topic somewhat?

  14. Lab Guy

    Lab Guy Well-Known Member

    Functional hallux limitus or rigidus caused by a tenodesis effect at the retrotalar pulley: description of the functional stretch test and the simple hoover cord maneuver that releases this tenodesis.

    Below is a post I wrote on 4/27/10. I have been manipulating the STJ for over 20 years and during that time have seen some very gratifying short term and long term results on a wide range of conditions but functional hallux limitus was not one of them. Neither was Plantarfasciitis. I also have FnHL and STJ manip never helped. Many Podiatrists (at least in the USA) manipulate the STJ but we do not put a name on it. I do not even know where the name hoover cord comes from.


    Re: Perception of Casting Patient's for orthoses at the Initial Visit
    Thank you Paul and Colin for your kind remarks.

    Markleigh, I will give you a little information regarding Micromanipulation. I realize this is an academic forum and I have no idea how Micromanipulation works.

    Dr. Crotty of Tulsa, OK, who has since passed away, developed micromanipulation. I spent a year learning Micromanipulation from a Podiatrist I worked for that was one of Dr. Crotty’s students. Sadly, Dr. Crotty never published any articles. I was told that Dr. Crotty called his form of manipulation, “Micromanipulation”, for two reasons. One being that he was manipulating the small bones of the foot and the other was that he was using minimal force rather than high velocity thrusting techniques. At its heart, Micromanipulation is the repositioning of subluxed joints of the foot using minimal force. To Dr. Crotty, if there were pain by the joint, then he would define it very broadly as subluxed despite not seeing evidence on radiographs.

    Due to the stress on the ligaments, muscles and joints of the foot during ambulation, it is common for pain to occur along the ligaments or tendons attaching or inserting at the joints as well as the common plantar inter metatarsal nerves. Pain in the foot can cause activation of trigger points of muscles within the leg, thigh, hip, shoulders and even head. Performing Micromanipulation has the potential to help relieve the pain and inflammation by bringing the joints back to their more normal anatomical positions and deactivating the trigger points proximally.

    What is the mechanism of action? I do not know. Academically, I really do not know why micromanipulation works and am not smart enough to know why. Yet, I have used it for 20 plus years and for me its one of my best tools in my toolbox. I also like it because you can never hurt someone using it as its very gentle and patients love being touched and obtaining immediate relief.

    Prior to doing Micromanipulation, I will get a baseline to see where my patient is in terms of points of tenderness in the lower extremity. In the following order I firmly digitally palpate along the iliotibial band, Pes Anserinus, shin, TN joint, sinus tarsi, plantar aspect and dorsal aspect of medial cuneiform and navicular, plantar cuboid, dorsal and plantar interspaces. I report areas of tenderness in my chart so that I can objectively quantify how my treatment is doing. My goal is that upon completion of treatment (with orthotics dispensed) that the above anatomical areas are no longer tender.

    The foundation of Micromanipulation is manipulation of the subtalar joint. When the STJ is manipulated, it causes the relaxation of the intrinsic muscles of the foot and extrinsic muscles of the foot and leg. It allows any subtle malpositioned joints to go back into place.

    Lets manipulate the left STJ. I am sitting in front of my patient who is sitting comfortably in the exam chair.

    My left hand cups the heel with my thumb resting on the anterior surface of the tibia and my fingers under the head of the fibula and on the lateral surface of the heel.

    I rest my right palm on the dorsum of the foot with my little finger on the head of the talus, my second, third and fourth fingers resting on the medial shaft of the first metatarsal and my thumb is resting over the met heads.

    Now, with my left hand cupping the left heel, I pull the heel distally, toward me, distracting and opening up the STJ. I hold this position for about 30 seconds. Then, with my right and left hands in the above positions, I again distract the STJ by pulling the heel and gently rock the foot. The forefoot is moving medially and laterally in the Transverse plane and the Tibia is internally and externally rotating. The Heel is not inverting or everting. You would really have to see it to understand it and even then you would have to practice it a lot before getting it down. Still, if you just open up the STJ by distracting the heel and holding it for 30 seconds, that can be very helpful.

    After manipulation of the STJ, I recheck all the tender spots/trigger points and often they are gone simply be manipulating the STJ. In Micromanipulation, the STJ is the most important joint to manipulate.

    After manipulation, I will apply taping with or without felt padding and instruct the patient to not go barefoot, and wear sandals in the shower. When the patient leaves the exam room and walking, the patient notices how relaxed and light she/he feels. They can feel as if they just had a one hour massage, it is quite amazing. You are helping to make your patient aware of the low grade pain they have been living with all these years.

    On the next appointment, I will recheck the tender points/trigger points to see if there is improvement and report those findings in my chart. I will manipulate again and I will also provide any other treatment that is necessary for the patient’s diagnosis. I will of course schedule my patient for a Biomech exam and casting for orthotics.

    There are many other Micromanipulation techniques and on this post, I focused on the STJ. Let me know if you’re interested in more information and I will post further. Micromanipulation is not a panacea but one of many treatment modalities that serves the patient. In my hands it has proven useful time and time again.

  15. Have you been chewing ergot or ingesting some of Dennis's chemicals lately, Robin? Maybe you are Benny Hill after all.....

    Attached Files:

  16. CraigT

    CraigT Well-Known Member

    Hi Lab Guy
    Thank you for your excellent description of your technique- it sounds similar to what Dr Paul Conneely teaches in Sydney... do you have any more you would be willing to share.

    In the above article, they describe a manipulation technique called the 'Hoover Cord' technique.
    I had never heard of Drs Hoover or Cord or their technique. As it turns out, they are likening the manipulation to releasing the power cord of a vacuum cleaner which has been jammed around the corner of a table... (FHL from around the posterior talus)... Ohhhh...THAT Hoover Cord...:D
  17. Lab Guy

    Lab Guy Well-Known Member

    . As it turns out, they are likening the manipulation to releasing the power cord of a vacuum cleaner which has been jammed around the corner of a table... (FHL from around the posterior talus)

    Yes, that makes sense, thanks for the insight. Later this week I will email you further information on manipulation. Thanks

  18. CamWhite

    CamWhite Active Member

    In the original post on this thread, the following remark was made:

    "Functional hallux limitus is a loss of metatarsophalangeal joint extension during the second half of the single-support phase, when the weightbearing foot is in maximal dorsiflexion. Functionally, it constitutes a sagittal plane blockade during gait."

    As a shoe store owner, specializing in comfort and pain relief, it amazes me at the sheer number of customers walking into our store with feet pointed outward, and severe lateral wear on the uppers and the outsoles of their shoes. To me, this is forensic evidence of a "sagittal plane blockade".

    When I look at their shoes and observe their gait, it's obvious that they are not "toeing-off" in a sagittal plane of motion. There's a slight (lateral) transverse plane of motion as they finish the gait cycle.

    Many of these customers complain of lateral foot pain, shin splints, knee pain, IT band syndrome, lateral hip pain and low back pain.

    It really doesn't take a rocket scientist to see what's going on. If functional hallux limitus is present, then we are forced to compensate. The compensation will be usually supination during the propulsive phase of the gait cycle, causing lateral stress on the lesser metatarsals, the lateral aspect of the ankle, knee pain, IT band stress, lateral hip pain and low back pain.

    I don't mean to sound so passionate about this subject (FnHL), but I see very little attention given to it. In an earlier post on this thread, I posted a link to a video and got very little response.

    In my experience, I am seeing this "sagittal plane blockade" in almost 90% of my customers. We are certified to sell the Cluffy Wedge in our store, and we have found it to be a simple and elegant way to overcome a 1st MPJ that wants to "lock-up". I am also aware that there are other approaches that claim similar results.

    What bothers me the most is that 1st MPJ function is rarely discussed, although references to that topic seems to be heating up lately.
  19. CraigT

    CraigT Well-Known Member

    Not sure i agree with this statement. It really depends on who it is you are talking to. It is commony discussed and recognised by Podiatrists, but perhaps not so much by other medical fields.
    You need to understand that there is great debate as to the significance of FHL and whether it is a cause or effect.
    After reading the thread on proximal vs distal influence of foot motion, there are possibly some parallels here?- does STJ pronation drive 1st ray function... and therefore cause a FHL... or does a FHL cause pronation? Food for thought?
  20. Also Cam I would be a little careful selling the Cluffy wedge to everyone, By forcefully dorsiflexing the 1st you may lead to structure changes in the 1st Metatarsal phangeal joint, so the Functional Hallux Limitus becomes Structure Hallux limitus at a faster rate. The Cluffy wedge may lead to an increase in bone on bone friction and compression forces. So short term relief maybe long term problems.

    As Craig T has said there is debate about if the Functional Hallux limitus is a cause or effect of Biomechancial changes.

    In the last 2 weeks I think we have had many disccussion on this.

    Check out this thread http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=49173
  21. james clough DPM

    james clough DPM Active Member

    I think it is very interesting that shoe salesmen can be astute enough to pick up that 90% of their clients have a sagittal plane blockede prohibiting normal foot function. Whatever you want to call this phenomenon, FHL, stiffness of the first MTPJ , or sag. plane blockade of motion, I would agree with his numbers on incidence of this condition. I will be submitting a manuscript of my findings on the incidence of this condition in clinical practice. Overall incidence of those with plantar fasciitis, PTTD, metatarsalgia, achillodynia/ enthesitis and shin splints, bunion pain, mortons neuroma, shows about 87% of these patients have a limitation of motion of the first MTPJ functionally.

    Prestressing the hallux in dorsiflexion is a reliable method of restoring unrestricted ROM to the first MTPJ. When doing this you will not cause structural limitation of motion, you are eliminaing jamming of the joint and restoring normal motion. If functional limitation continues over a long period of time the effects of this compression force in the joint will result in either dorsal or medial displacement of the first metatarsal with either hallux rigidus or bunion deformity. This depends on the axis of the first ray and anatomic and genetic factors.

    A very simple way to appreciate the prevelance of this problem is to just watch your patients walking in your office. Do they have the gait pattern described by Dr. Perry in her book on gait analysis. Far from it in my office. If the first MTPJ is stiff there is no way they can walk this way, so we first have to allow the joint to bend, then we have to work with our patients to retrain them to use the motion for a more effective gait. It is not just a matter of putting something in the shoe and wishing them well. You need to take a more holistic approach to this disorder. I believe as a whole, though , that the disorder is grossly under appreciated. And I think it is great that the shoe people are aware of this.

    I believe first MTPJ motion is probably the most important thing we need to address with shoes and orthotics( arguably). If the plantar fascia is not able to stabilize the foot in propulsion the game is over. This simply must be restored for normal foot stability to occur.

    I have also made an observation on the cause of stiffness of the first MTPJ. My surgical practice has allowed me to make some observations on this. I can reliably restore a functionally restricted joint by cutting the medial collateral ligament during bunion surgery. I believe there is a tension banding effect of this ligament which prohibits normal motion from occuring. As the first metatarsal elevates the ligament changes in orientation, essentially moving plantar to the axis of rotation. This restricts motion of the joint. This seems to happen everytime on a bunion surgery. Interesting observation? Has anyone else observed this?
  22. Nice observation, and welcome. How much frontal plane rotation do you see with first metatarsal dorsiflexion? Roughly how many degrees of frontal plane rotation are needed for the collateral ligament to impede dorsiflexion at the 1st MTPJ in your experience?
  23. james clough DPM

    james clough DPM Active Member

    it is difficult to assess frontal plane motion of the first metatarsal in surgery as the first metatarsal elevates, but based on what I see it is not that significant. What is your theory on frontal plane motion and how this ties into FHL?

    I do a lot of first met. cun. fusions when doing bunion surgery. These people never have, nor develop FHL once the medial column is stabilized and the first met. is brought to its normal position in the sagittal plane. In my view this is more of a sagittal plane issue.
  24. Peter

    Peter Well-Known Member

    As a shoe store owner, specializing in comfort and pain relief, it amazes me at the sheer number of customers walking into our store with feet pointed outward, and severe lateral wear on the uppers and the outsoles of their shoes. To me, this is forensic evidence of a "sagittal plane blockade".

    Or maybe that the axis of the ankle joint lies approx 20-30 degrees from the frontal plane?
  25. james clough DPM

    james clough DPM Active Member

    Peter, I agree with your observation. There are in fact quite a few people who compensate for their sag. plane blockade by abducting the foot. When doing so, you can move forward without moving the first MTPJ in dorsiflexion. It is difficult to generalize this situation that all of this originates from a sag. plane blockade of motion, however, I believe all of these will get a sag. plane blockade of motion. Suprastructural orientation will often also dictate the position of the foot. In other words, external rotation of the hip or malleoli will predispose one to this posture as well. Severe midfoot instability and rearfoot pronation can also cause abduction of the foot. No matter what the cause of this, the problem remains, from a functional standpoint, a significant one.
    This gait pattern, over time, will cause a significant ground reaction force under the first met. head, as they are largely propelling off the met. head. This will in turn, elevate the first met. and cause functional jamming of motion of the first MTPJ. My contention here is that this foot will most likely demonstrate limitation of motion of the first MTPJ.
    It is imperitive to re-establish motion of this first MTPJ , but equally important to address the muscular issues, if possible, that are limiting the ability to walk over the foot properly. Some degree of physiotherapy is necessary here. Prestressing the hallux in dorsiflexion is the best method of doing this that does not apply a pronatory force to the foot ( as is the case with a reverse mortons extension), or create instability of the medial arm of the tripod of support for the foot. When creating a defect under the first metatarsal head you will find the foot to pronate through this in late midstance which is usually contrary to what we are trying to accomplish.
    I would agree with you that this angle of gait seems very common, particularly among men. See this link on how pre stressing the hallux in dorsiflexion works http://www.youtube.com/watch?v=Gn7UqZDX0yM
  26. drdebrule

    drdebrule Active Member

    I enjoyed this thread and reading the article in JAPMA. Vallotton makes a strong case for the retrotalar pulley as one cause of functional hallux limitus. FnHL must be multifactorial as noted by the discussion above and the paper alludes to this in their discussion too.

    I enjoyed Dr. Clough's comments regarding the Cluffy wedge. I use this device in my practice and have had good success. I hope further medical studies will look at the Cluffy versus other orthotic modifications (kinetic wedge, reverse morton, casting with 1st ray plantarflexed etc.) to help us determine what works best or what is more appropriate for a given foot type.

    I am curious as to how often the Hoover cord manipulation needs to be repeated? How long can a patient maintain this apparent increase in great toe dorsiflexion without stretching, orthotics, and/or gait retraining?

    Also, I should note that the study would have been stronger if they had long-term follow up and actually measure great toe dorsiflexion during gait.
  27. james clough DPM

    james clough DPM Active Member

    There is research needed to validate much of what we do in clinical practice. I am amazed, quite frankly, at how popular the RME and frist ray cutouts have become without any validation in the medical literature on their effectiveness at improving first MTPJ motion or first metatarsal head weight bearing pressures.

    Two research studies are being done on a wedge under the hallux. Please see my website at cluffyinstitute.com for access to a study done at Temple University School of Podiatry. Another study is currently under way. If anyone has an article looking at kinematic changes of the first MTPJ or pedobarographic studies with RME, first ray cutouts, and/or Kinetic Wedge modifications, would you please send me those references?
  28. Here you go:http://www.asbweb.org/conferences/2003/pdfs/163.pdf

    I just realised I've never read this: http://www.ncbi.nlm.nih.gov/pubmed/3367295

    If anyone could do me the honour...
  29. Simon JAPMA did not have a copy online so I'm out Ian ?

    I also would not mind a look see if anyones got a copy.
  30. james clough DPM

    james clough DPM Active Member

    Thank you for the references, Simon. This reference is just a letter to the editor desribing the Kinetic Wedge, it is not a research paper. http://www.ncbi.nlm.nih.gov/pubmed/3367295. A very basic description of how the kinetic wedge works.

    Good material on the other studies with the kinetic wedge. No improvement of first met head weight bearing pressures noted. More pressure under the first would be expected with increase in dorsiflexion of the hallux. No significant change in fifth met head weight bearing pressures noted. This would be expected if the trajectory of force changes to a more medial position. Not a good addition for lesser met.overload. This is what would be expected with a higher durometer of material under the lesser mets. No changes in gait posture really appreciated either.

    Does this help clarify things, Mike?
  31. James, I tried to read the stuff on your website regarding kinematic and pressure changes, but the poster it links to is really too small to read and when you zoom in it just get too blurred. Is there a published paper this relates to? Or could you attach something a bit larger and more legible here?
  32. james clough DPM

    james clough DPM Active Member

    You may try to print the poster. This makes it a little easier to read. Perhaps if you print in a larger page format it would be easier to read? I will see if I can do anything to improve the quality. The researchers have not published their results to date. I believe they intend to do this.

    If you are not successful in printing out the poster, leave me your contact and I will send you a readable version.
  33. Thanks, I should appreciate that. From what I can read, it would have been nice to have seen what the medial arch support achieved in isolation, without your product in-situ. Since it seems that it was only when this was introduced that statistically significant differences were observed.
  34. If functional hallux limitus is such a problem for gait function, then why, when I perform fusions to the 1st metatarsophalangeal joint, do the function of patient's feet generally improve and the foot become less pronated??

    In addition, how does one lengthen the plantar fascia with this "Hoover cord maneuver"? The plantar fascia is the main deforming force causing functional hallux limitus, not the flexor hallucis longus. If the flexor hallucis longus was the main deforming force for creating functional hallux limitus, then why doesn't this tight flexor hallucis longus cause flexion of the hallux interphalangeal joint instead of causing functional hallux limitus?

    So many questions, with no answers from this paper. As you can see, I'm not very impressed.:butcher:
  35. that is, your product did not achieve statistically significant change in isolation. the question becomes, would the medial longitudinal arch support have achieved statistically significant change without your product?
  36. james clough DPM

    james clough DPM Active Member

    Right, I wish that would have been tested as well. At this point we do know that the two modalities together are effective at improving 1st MTPJ ROM functionally. This study did not show statistically significant changes in pressures on the first through 5th mets, however, you will note, none-the-less, that changes were present.
    Other research pending right now on prestressing the hallux in dorsiflexion is showing statistically improved pressures on the first met head both mean and peak. This should also correlate with increased motion of the first MTPJ. This kinematic data is pending. This is looking at a hallux wedge in isolation. I look forward to getting this data shortly.
  37. NewsBot

    NewsBot The Admin that posts the news.

    Sagittal plane blocade in patients with Functional Hallux Limitus:a multisegment model analysis of the Flexor Hallucis Longus endoscopic tenolysis
    Tzioupis, Chris; Diehl, Stephan; Rouhani, Hossein; Arami, Arash; Aminian, Kamiar; Vallotton, Jacques
    Presented at: 13th International Symposium on 3D Analysis of Human Movement (3D AHM), Lausanne, Switzerland, July 14-17, 2014
  38. NewsBot

    NewsBot The Admin that posts the news.

    Sagittal plane blocade chez les patients présentant un hallux limitus fonctionnel (HLF). Résultats après ténolyse endocopique du tendon du long fléchisseur de l’hallux par un modèle multi-segment, une étude comparative et prospective
    Jacques Vallotton, , Arash Arami, Hossein Rouhani, Kamiar Aminian, Chris Tzioupis
    Revue de Chirurgie Orthopédique et Traumatologique; Volume 100, Issue 7, Supplement, November 2014, Pages S238–S239
  39. NewsBot

    NewsBot The Admin that posts the news.

    Hallux limitus fonctionnel (HLF) et rupture du LCA : liens de causalit?, pr?vention et solutions th?rapeutiques. Functional hallux limitus (FHL)
    J. Vallotton, , C. Tzioupis
    Revue de Chirurgie Orthop?dique et Traumatologique
    Volume 101, Issue 8, Supplement, December 2015, Pages e11


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