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Advice for hallux limitus with very hyperextended IPJ

Discussion in 'Biomechanics, Sports and Foot orthoses' started by issy1, Aug 3, 2010.

  1. issy1

    issy1 Active Member


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    36 YEAR OLD FEMALE, VERY ACTIVE CYCLIST AND HILL WALKER.

    C/O VERY PAINFUL SUB 1ST I.P.JS WITH HARD CORNS AND THICKENED BIG TOE NAILS.

    PATIENT HAS LARGE ARTHRITIC 1ST M.P.J'S WITH THE MOST HYPEREXTENDED I.P.J'S I'VE EVER SEEN. SHE HAS LOW DORSIFLEXION STIFFNESS OF 1ST RAYS, VERY LIMITED DORSIFLEXION OF BOTH HALLUX WHEN STANDING ALOT OF FORCE IS REQUIRED TO DORSIFLEX BIG TOE (PULLING FROM BEHIND I.P.J) AND VERY LITTLE ARCH FORMATION IS ESTABLISHED. SHE HAS HIGH SUPINATION RESISTANCE IN BOTH FEET, LOW GEAR PROPULSION.

    A PODIATRIST IN THE HEALTH SERVICE STUCK A FELT SHAFT PAD TO 1ST I.P.J. ONTO AN INSOLE BUT GAVE NO RELIEF. IS IT WORTH MAKING ORTHOTICS FOR THIS PATIENT WITH RF POSTING /IST RAY CUT OUTS/ FOREFOOT VALGUS POSTING ETC TO TRY AND ENGAGE WINDLASS AID HIGH GEAR PROPULSION. WOULD THIS STOP I.P.J. WORKING SO HARD OR WOULD SHE BE BETTER JUST BUYING PAIR OF MBT'S.

    WOULD APPRECIATE ANY IDEAS ON HOW TO GIVE BEST I.P.J. RELIEF AND STOP HYPEREXTENDED BIG TOES GETTING BASHED AGAINST SHOE UPPER.
     
  2. Graham

    Graham RIP

    Only use a first ray cut away if you have "adequate" (sorry simon:craig:) dorsiflexion at the MTPJ. If you do a Kluffy wedge would likely be usefull to pre load the hallux.

    Without adequate dorsiflexion at the MTPJ a rocker sole modification would help with a simple redistributive insole for the lesions.
     
  3. davidl

    davidl Member

    Issy1
    quick footwear issues - check she has the correct size boot - about 90% of ladies tend to wear a size too small. Check sole stiffness of walking boots - she will need quite a stiff sole rockered at MTPJ level asa Graham has already mentioned. Does she have the above but has 'skinny' ankles/shins? - maybe slipping forward in boot downhill - try SCF tongue padding. If all OK a dorsal scf prop over 1st ipj can work i.e. to fill in the void and spread the load (if it stays in place) - I do not think the IPJ will 'stop' hyperextending regardless
    David
     
  4. Have you and/or the patient considered a surg consult ?
     
  5. issy1

    issy1 Active Member

    SHE CERTAINLY WILL BE A SURGICAL CASE EVENTUALLY AND I HAVE ADVISED HER OF THIS BUT I HAD HOPED TO BE ABLE TO DELAY THIS FOR ABIT LONGER OR A LEAST UNTIL SHE HAS COMPLETE STRUCTURAL HALLUX RIGIDUS.
     
  6. issy1

    issy1 Active Member

    I DID NOT THINK KLUFFY WEDGE WAS SUITABLE FOR THIS PATEINT BECAUSE WHEN YOU PICK UP HER BIG THE IPJ DOES ALL THE DORSIFLEXING - SO MUCH SO I FEEL I'M GOING TO DISLOCATE IT. I FELT KLUFFY WOULD ONLY DORSIFLEX I.P.J RATHER THAN M.P.J. AND ALSO MAY MAKE NAILS WORSE.

    I FILLED THE GAP BETWEEN M.P.J. AND I.P.J WITH SCP FELT AND THIS DOES PLANTARFLEX THE HALLUX SLIGHTLY BUT SHE WOULD HAVE TO DO THIS EVERYDAY HERSELF - WOULD IT NOT BE DIFFICULT TO POSITION THIS SMALL FILLER MATERIAL ON INSOLE AND MAKE SURE IT LIES IN CORRECT POSITION.
     
  7. Is you keyboard broken ?

    Why wait ?, if a Surgeon looks at the joint and can reconstruct the joint and do something with the extension deformity at the IPJ then you can get stuck in with your orthotics.

    Remember we are working with forces - you have said that the problems with the extension deformity and shoe rubbing, how are you going to cause a plantarflexion moment on the hallux at the IPJ ?

    If you doing anything that causes a Dorsiflexion of the hallux the shoe stress will increase.

    So the options you have are surg which maybe more benefit to the patient to have now then orthotics - but you would need to find out.

    Cut holes in her shoes to decrease the shoewear pressure.

    Or maybe pronating the STJ to get a negative windlass, plantarflexion moment at the 1st MTP which would lead to less shoewear pressure on the dorsal hallux, which might be abit outthere.

    or a Good rocker with increased toe box height, but won´t be much of a hiking boot.

    You have mention a FF valgus post to attempt to decrease Dorsiflexion stiffness of the 1st - if you were successful with this would not the 1st MTP joint dorsiflex more and therefore be greater show wear stress on the extension deformity of the IPJ ?
     
  8. issy1

    issy1 Active Member

    PERHAPS I SHOULD HAVE SAID PATIENTS ALSO RELUCTANT TO HAVE SURGERY IF POSSIBLE BUT I THINK YOUR RIGHT THERE PROBABLY IS NO POINT IN PUTTING IT OFF.
     
  9. Graham

    Graham RIP

    ISSY1,

    JUST AS AN ASIDE. QUIT THE CAPITALIZATION OF EVERY WORD! IT'S INTERNET SHOUTING!

    Sorry! Couldn't hear myself write!
     
  10. Try a reverse Mortons extension 2-5
     
  11. issy1

    issy1 Active Member

    s

    SORRY - LAZINESS!
     
  12. issy1

    issy1 Active Member

    SORRY - LAZINESS!:D
     
  13. Asher

    Asher Well-Known Member

    Hi Issy,

    Yes, A Cluffy wedge will just elevate the whole hallux such that the distal/dorsal aspect of the toe will push up into the shoe even more and irritate the nail.

    You are on the right track, in my opinion. This padding will put the MPJ in slight dorsiflexion (and as long as there is a little MPJ dorsiflexion available, will be tolerated) while allowing the IPJ to plantarflex somewhat and reduce pressure on the distal/dorsal aspect of the toe.

    Rebecca
     
  14. alwinliew

    alwinliew Member

    So this is structural hallux limitus? Plantarflexing the 1st MPJ would still not gonna help to improve 1st MPJ dorsiflexion, try Morton's extension to reduce/ offload the pressure to dorsiflex the hallux.

    Alwin, Perth
     
  15. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    NO!

    This is OSTEOARTHRITIS! (sorry, got carried away with all this 'shouting').

    I do wish we would all get over this functional, fictional, structural, abstract and post-modern hallux limitus business.

    Every other joint in the human body with degenerative joint disease is deemed by diagnosis to have osteoarthritis.

    Osteoarthritis, is osteoarthritis, is osteoarthritis. In the 1st MTP joint, it goes through a well described clinical and radiographic process of deterioration in the direction of ankylosis. Like everywhere else.

    And like every other joint with OA, the process of conservative, pharmacological and surgical approaches are more or less the same. Hyperextension of the 'joint below' is also a well understood process of compensation for OA. It usually signifies late stage DJD, and is often the time to start talking surgery.

    Do the orthotic thing, muck around with shoes, but give it no more than 3-6 months before referring for a surgical consult if pain persists.

    LL
     
  16. Yeah man. Basically you've got two orthotic options you can offload the 1st MTPJ with a reverse Mortons extension as I suggested, or you can increase the load of the 1st MTPJ with a Mortons extension. I've had success with both in the past, more so recently with the reverse Mortons. But as ya' man says you'll know pretty rapidly if conservative measures are going to work, and if they don't, you need to talk about the chopping option. Inform them of the chances of a positive outcome, potential complications etc. and let them decide.
     
  17. alwinliew

    alwinliew Member

    Yes Simon, I agree with what you said. I usually do mention about "Osteoarthritis of the big toe joint" as there is degenerative changes in the joint, but, I also use structural hallux limitus interchangebly. University taught me that terms, books also use that term, so I thought I also use this term, just to differentiate functional vs structural.

    Thanks anyway.

    ALwin
     
  18. alwinliew

    alwinliew Member

    Hmm, I usually use Morton's extension to just before the hallux for OSTEOARTHRITIC 1st MPJ, and Reverse Morton's for a plantarflexed 1st ray/ functional hallux limitus. What do you think?

    Alwin, Perth
     
  19. I think you shooting the wrong messenger- it was LuckyLisfranc that posted about osteoarthritis.
     
  20. I'll usually put the Mortons up to the IPJ. I use the reverse Mortons to offload the 1st MTPJ, I've used this successfully with structural hallux limitus in numerous patients.
     
  21. Peter

    Peter Well-Known Member


    Hi Simon,

    What is your preferred material for the reverse/Mortons extension?
     

  22. I use a high density eva
     
  23. davidl

    davidl Member

    I am interested in what kind of surgery would be considered in a very active 38 year old patient.
    I'm no surgeon and thus need to be enlightened on the latest and greatest, but I most commonly see some sort of fusion (approx 15 degrees) in this type of patient from our local orthopods. Would she be any better off considering it is sub IPJ not MTPJ pain that is main concern?

    respectfully
    david
     
  24. I guess if Issy posts up some x-rays we are more of a chance to get into the surg discussion.

    and maybe some more info on ROM

    but I´m not a surgeon so what do I know......
     
  25. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Depending on a vareity of factors - most commonly surgeon preference, the options of any osteoarthritis joint are;

    1. fusion
    2. replacement
    3. other joint sparing alternatives (eg cheilectomy, interpositional arthroplasty)

    If the IPJ is already 'very hyperextended' - then one must assume (without radiographic and clinical info) that there is probably relatively advanced OA in the 1st MTP joint.

    Depending on your country, training and preference some will go for fusion, others may believe in the reliability of prosthetic replacements. Some will place a buffer of joint capsule within the 1st MTPJ and remodel the head (interpositional arthroplasty). There are other options for less severe OA.

    Whilst commonsense would dictate that keeping ROM in the 1st MTP joint is the most desirable outcome (ie replacement), many believe that the reliability of fusion is hard to better.

    LL
     
  26. efuller

    efuller MVP

    You mentioned a high supination resistance test.
    Why don't you add a medial heel skive. One behavioral way to avoid pain at the 1st MPJ is to supinate at heel lift. If the PT muscle needs some help because there is a really flat foot with a medially deviated STJ axis then the medial heel skive could help reduce the stress on the MPJ.

    There was also a mention of a very arthritic 1st MPJ. How much range of motion is there non weight bearing. I saw that there was essentially zero weight bearing.

    In my experience, a large amount of IPJ hyperextension is associated with the ability to tolerate a lot of pain.

    Cheers,

    Eric
     
  27. davidl

    davidl Member

    Thank you for your answer LuckyLisfranc, and I too have assumed that the case highlighted has advanced OA.
    I rarely see prosthetic replacements in anyone other than elderly (in UK by the way) as I have not heard particulalrly good reports about the longevity of these devices i.e. approx 10 years. In your experience, how long do they tend to last (for an average active person), is it dependant on type of prosthesis and can they be replaced when worn out?
    Thanks in anticipation
    David
     
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