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I'm looking for some thoughts about a patient I saw recently who was referred to me by our DPM for orthotics. He diagnosed pes cavus and hallux valgus.

She is a 51 y.o. ER physician who complains of severe pain at her 1st MTP joint at the end of the work day. Her pain occurs with plantarflexion and dorsiflexion of the joint to the point that she has a hard time using her foot to step on the gas pedal after work because plantarflexion of the hallux is so painful. She generally wears an open dress casual shoe (like a Merry-Jane without the strap) but wore sneakers recently for 13 hours and had very little pain afterwards. Her x-ray was read as normal although clinically she appears to have some minor hypertrophic bone on the dorsolateral surface of her 1st MTP. As I recall she may have had a mild grade 2 (at most) hallux valgus (using the Manchester scale). Mechanically she has a large forefoot valgus in STJN and ambulates with a relatively "supinated" foot through the stance phase of gait (inadequate pronation coming into midstance). She has about 90 degrees of passive dorsiflexion at the 1st MTP joint.

She has a clean joint with lots of available motion that hurts with plantarflexion as well as dorsiflexion when irritated. She is much better in sneakers than shoes.

Any thoughts on what's happening here?

Thank you very much!

Ann

 

did you perform a Jack's test?
is the supinated gait due to compensation to avoid the painful joint?
does the Pt have a hypermobile 1st Ray?

 

Ann,
Are you familiar with the concept of a functional hallux limitus. There are several threads on this site that go really deep into the theory of FnHL as well as treatment.

Cheers,

Eric

 

Thank you for the responses.

I am familiar with functional hallux limitus and she does not have it. She has excellent motion in weightbearing and NWB at the MTP joint. She also does not have a hypermobile first ray. I don't believe her gait pattern has changed to avoid pain because there is no significant difference between her right and left foot in terms of gait. I'm not familiar with the Jack's test but know there was a recent thread about it that I will look at.

Thank you!

 

Perhaps a subtle osteochondral lesion on the metatarsal head is being overlooked here?

If lucky (with narrow region of interest, thin slices through 1st MTPJ, using an extremity coil), an MRI may detect this, otherwise it may not be obvious until surgical exploration and debridement.

LL

 

Does she have calluses? What impression is there in the shoe from the foot? Is there evidence of high load 1st met and hallux?

What is the gait. Is there late stance phase pronation. Often people with lat dev STJ axis will have late stance phase pronation causing high medial load and high stress on 1st MPJ even though clinical exam shows no functional hallux limitus.

The pain in the joint sounds exactly like what I get with my functional hallux limitus (when I don't wear my orthotics), but I do have a little dorsal osteophyte.

Regards,

Eric