Lateral Forefoot Elevation Test

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I can't recall exactly where but someone made mention of a "Lateral Forefoot Elevation Test" as part of their assessment for functional hallux limitus. Could someone please provide further info. on this test?

 

unsure of the exact name, but i often play with various forefoot positions (either varus/valgus) when assessing for a functional block (weightbearing/nonweightbearing). I find it useful in deciding what forefoot additions i need to optimise 1st MTPJ function

 

Hi Mark,

I am pretty sure this test has been described by Eric Fuller a couple of times on Podiatry Arena. I am not sure which thread/s this has been already been discussed in, but hopefully, if Eric is reading along, he might be able to chime in.

It has always been my understanding that this test allows us to ascertain how much intirnsic/extrinsic forefoot valgus correction the patient is able to tolerate in an orthoses prescription. For example, if the patient is unable evert there forefoot during static weight bearing, then it is unlikely that they are going to be able to tolerate large amounts of forefoot valgus correction. However, I am unsure as to how this test would be a good predictor of whether somebody has a functional hallux limitus (FnHL). Could you please explain why you would use this test as part of your assessment for FnHL?

I currently use the Jacks Test and the modified FnHL test as part of my assessment for FnHL. In addition, I also observe observe how the 1st MTPJ is functioning during the gait exam. Sometimes, static and NWB tests have poor correlation to dynamic function.

Regards,

Dan

 

I call this test Maximum eversion height. The purpose is to attempt to assess the range of motion available, when someone is standing, of the Subtalar and Midtarsal joints. I developed this test after reading a lot of Root, Orien, Weed and thinking about measurement accuracy. John Weed's prescription writing protocol was essentially based on not everting the foot farther than it can go within its normal range of motion. I think this is a very important concept that I got from their writings. I've had orthotics that have tried to evert my foot more than normal range of motion and they gave me sinus tarsi pain. (Read Kevin's rotational equilibrium paper for explanation of why this would happen.) I've also seen people who've had too much intrinsic forefoot valgus correction in their orthotic whose pain was under their lateral forefoot instead of the sinus tarsi. So, the point of the test is to find out how far you can evert the forefoot without causing pain. (It is also important to understand how an intrinsic forefoot valgus post changes the height of the lateral forefoot when the foot is on the orthotic.)

The treatment of functional hallux limitus is to decrease load on the windlass mechanism. One way to do this is to increase load on the lateral forefoot. John weed described placing fingers under the lateral forefoot and talked about some people who had very little load there. In my experience, there are some, not all, people with functional hallux limitus who have very little weight on their lateral forefoot. They seem to get reduced symptoms when you add an intrinsic forefoot valgus post (or any kind of valgus post). For theory see my paper on windlass mechanism of the foot in JAPMA in 1999 or 2000. Sorry I'm away from my home computer for the exact ref.

Regards,

Eric Fuller

 

We have taken this test one step further and started measuring the force to elevate the medial and lateral forefoot columns. We using the device we developed to measure supination resistance. What struck us immediately is the massive differences between people in our much force is needed to elevate the lateral and medial columns ... it has to mean something for function.

There have been a few people I have seen that have what I have called 'lateral overload syndrome' (for lack of a better name) in which when you put your fingers under the lateral two met heads, you can not lift the lateral column (that if you can even get the fingers under there!). Now using the force gauge to quantify the force and relate that to function, and hopefully symptoms.

 

Craig:

This condition was named first, to my knowledge, by one of my classmates from CCPM, Steven Palladino, DPM (a teammate of mine on the UCD X-country/track team and a 2:16 marathoner). He lectured at CCPM at an "Essentials of Practice Seminar" on November 16, 1996 and called the syndrome "Lateral Column Overuse Syndrome" which he described as occurring in 4% of his patients with pain at the CCJ or cuboid-metatarsal joints in a four month study of this patients.

I call the disease "Lateral Dorsal Midfoot Interosseous Compression Syndrome", but it is basically the same disease as Dr. Palladino originally described. I wrote about it in February 1997 in my newsletter on Dorsal Midfoot Interrosseous Compression Syndrome - Volume I (Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997, pp. 165-166).

 

I was thinking more of those patient who appear to have an 'overload' of the lateral forefoot plantar tissues; vague symptoms; non-specific diagnosis.

 

Mark

I use the test this way - while the patient is standing they are asked to role on their medial border and raise the lateral arch. I then place my finger underneath the 5th met head and very subjectively assess how much force they are exerting - I like the idea of quantifying this via Craig's method.
If the patient exerts minimal force we assume that they have a flexible (Less stiff) lateral column . On F-Scan assessment the COP can be seen to stay lateral for longer in the gait cycle then rapidly accelerate towards the medial border - often accompanied by overload of the prox phalanx of the hallux (FnHL?)
Symptoms locally include medial overload, cuboid pain etc.
However the greatest value seems to be at the knee and hip. When lateral sulcus posting and shell mods are used to artificially dorsiflex the lateral column, the changes in velocity and timing of external tibial rotation seems to be a panacea for over use injuries of the knee associated with transverse plane related symptoms - those ones where no one seems to be able to give a definative diagnosis.

I would dearly love to assess this via Vicon etc but if wishes were ..........

Note of caution, the longer lever arm of sulcus posted orthoses can mean that the effects of the posting can be very significant - start small and work up.

Cheers

Phil

 

The looking at the amount of load is very interesting. In placing fingers under the lateral forefoot I have been very surprised at the difference in range of motion available when there is a high load on the lateral forefoot. There is the classic forefoot varus foot that has no range of motoin available and there is the laterally deviated axis / easy supination resistance foot.

The lat dev STJ axis foot has a high lateral load because there is so little foot on the lateral side of the axis. To be in equilibrium the Force x distance from all points on the lateral side of the joint has to equal the force x distance from all points on the medial side of the axis. Small distance means larger force. These feet will have high lateral loads and they may or may not have a large range of motion available to lift the lateral forefoot off of the ground.

Cheers,

Eric

 

Hi Phil

Wow, I stuck my finger under a 5th MPJ yesterday after reading this post and almost had my distal phalanx crushed. Then I was silly enough to do it to the other one.

The foot-type was large tibial varum with inverted heel at stance & gait. So all available rearfoot pronation is being used but still inverted at heel. And all available midfoot pronation being used but callus under 5th MPJ - very high force.

Thanks for the thread markleigh and Eric!

Rebecca

 

Rebecca,

You should still ask the patient to evert, or put a block (Coleman block test) under the lateral forefoot to see if the calcaneus everts. I've had my finger crushed by people with range of motion available. The first time I saw it, I had to think quite a while before I figured it out. It was a observation that did not fit the Root paradigm.

Your Welcome,

Eric

 

Thats the point I was trying to make above --- when you try and put your fingers under there, there is a massive variation from person to person in the force. I think I know what that means (others may disagree), but given that variability, it has to mean something for function.

 

What do you think it means and why would other disagree?

Rebecca

 

Rebecca

Sorry about that, I forgot to put the warning in about 'podiatrist finger injuries'
The same has happened to me so I now tend to pick the patients very carefully.

Phil

 

The point I like to make often is that when you do a range of clinical tests (eg supination resistance; windlass function, functional hallux limitus; and this lateral forefoot elevation test; and a thread I will soon start on the forefoot stability test), there is wide variability from person to person and often from the left to right foot. The fact that there is this variability means that it must mean something for function.

Where the disagreements may lie is not that the variability exists and the impact that this may have on function, but in the theoretical interpretations to explain the effects on function.

In the case of this lateral forefoot elevation test, then I think it could explain the lateral overload syndrome (both versions that Kevin and I mentioned above). It could also explain a delay in the transfer of weight from the lateral to medial column during propulsion. One theoretical explanation is based on Bojsen-Mollor's high gear low gear - ie a high lateral load may mean that that there is no or a delayed transfer from the oblique (low gear) to the transverse (high gear) axis .... where the problems lie, is that many do not agree with Bojsen-Mollors concepts.