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I have a question regarding orthotic prescription variables / modifications for management of structural hallux limitus.
The patient is a healthy, fit and active 61 year old female with pain in the 1st MTP jt experienced during brisk walking (walks 2kms daily). Pain has slowly worsened in the past 2 years, but does not stop or limit activity.
Exam reveals no significant biomechanical abnormalities aside from a slight reduction in 1st ray dorsiflexion stiffness and a reduced total ROM at the 1st MTP jt (approximately around 35* - 40* from memory). And a degree of functional hallux limitus determined by the Hubscher maneuver.
Plain films reveal moderate joint space narrowing with subchondral sclerosis and dorsal osteophyte formation in keeping with moderate to marked osteoarthritic change. The other thing I noted on the lateral view was a relatively dorsiflexed 1st metatarsal with the base of the prox phalanx sitting slightly lower and not articulating in a totally congruent way.
My treatment plan (lets call it treatment plan A) involved orthotic therapy with a Morton's extension under the 1st MTP jt to dorsiflex the met head and plantarflex the hallux and therefore reduce dorsal jamming of the joint during gait....
However, I am now thinking that maybe I should have done the opposite (Lets call it treatment plan B) - an orthotic with a first ray cut out and a reverse Morton's extension to encourage plantarflexion of the 1st met head and facilitate better joint function and activation of the windlass mechanism?
At what point of structural joint limitation do you stop trying to do treatment plan B and decide on treatment plan A??
Thanks for any thoughts
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