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Treatment of Hallux Valgus with orthoses

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Pod on sea, Mar 2, 2010.

  1. Pod on sea

    Pod on sea Active Member

    Members do not see these Ads. Sign Up.
    With an adult patient, on what do you base the decision to prescribe an orthotic for painful Hallux Valgus vs refer for surgery (or give no treatment)?

    Orthoses give relief from hallux valgus pain according to this quote from a 2008 Cochrane review ''This review shows that for people younger than 60 years of age with painful hallux valgus (a condition where the base of the big toe bulges out sideways, away from the foot) custom-made foot orthoses:
    Reduce foot pain after 6 months compared to no treatment, but may not reduce foot pain after 6 or 12 months compared to surgery".

    Does anyone know what the longer term outcomes are for orthoses vs no treatment?

    We all know what we do as individuals and why, but are there any established protocols?
  2. We've Kind of just finished one so GPs know where to refer whom. It basically is a flowchart designed to differentiate in broad strokes between fnHL, SHL, and pain caused by superficial irritation of an overlying bursa.

    It's necessarily crude (has to be quick and simple so GPs can use it) but it might be a start.

    If you send me an email I'll send it you.

  3. Can you post it here for peer review, Robert?
  4. If you'd be interested.

    I will emphasise that this is for use by GPs and other non podiatrists to decide where to refer. I make no claim that it will hit the best answer 100% of the time, its just to try to reduce the number of people who end up with the surgeon instead of the biomechanist and vice versa.

    Also by way of disclaimer I will say that it is A: a work in progress and B: a compromise between me, my boss and the commissioners. And yes there are holes in it you could drive a truck through.

  5. Problems I can still see with it:-

    The "is it managable" box is tautological

    You can have SHL with no superficially visible osteophytes and they end up in the FnHL box.

    Lots of people will have SHL or FnHL AND superficial bursitis. Or even all 3. People don't fit into the neat either or boxes our masters demand we put them into.

    Its a debasement of the science.
  6. OK, 10 second review. How do you judge whether the inter-metatarsal (presumably 1st- 2nd) angle is greater than 15 degrees? Should this read hallux abductus angle?
  7. G Flanagan

    G Flanagan Active Member

    Robert its a start, i wish something like this was in place in my part of the country. However three problems;-

    1) To determine the IM angle you would have to chart a plain film.

    2) GP's (the majority of the time) only get to see the radiologists report.

    3) Even if GP's did get to view the film, they couldnt chart it. Given that the difference in Podiatrists charting films is substantial let alone GP's
  8. Could be, could be...

    But the document the commissioners had already used 15 degree I m angle as the threshold. So they wanted that in there.
  9. Lawrence Bevan

    Lawrence Bevan Active Member

    why not, if it doesnt hurt live with it.
    anyting else send to podiatry to be triaged and/or treated accordingly.
  10. I suggested that. The surgeons threw a pout. Their idea was that THEY triage everyone, and refer to biomechanics as appropriate. Much as the orthopod / surgical appliance setup.

    Besides, we've just had a service cut. Can't see low risk adults any more, much less triage the surgery patients.

    Nhs politics. Got to love it.
  11. Pod on sea

    Pod on sea Active Member

    Interesting, so would they (commissioners) expect to X-ray each painful HAV case to have the angle checked? It's ok in theory but in daily practice who is going to do that? Surely we need a quick (possibly visual?) reference guide for GPs to work off.
  12. Lawrence Bevan

    Lawrence Bevan Active Member

    I participate in a service that triages foot surgery. 3 out of 4 dont have surgery, at least 1 out of 4 is because they change they're mind when honestly informed on the risk of complications and the time to recover/off work. Put that in a box! :)

    Cost to the NHS to see a surgeon that tells them dont need surgery vs cost of non-surgeon? sounds like they are budget-cutting the wrong service.
  13. Pod on sea

    Pod on sea Active Member

    Aside from Robert's flow-chart has anyone else attempted to define a protocol?
    What does everyone else do, especially in private practice where there's no formal triage set-up? Do you try orthoses (+ footwear advice) or refer straight to a surgeon?
    The other query I had was this ..Does anyone know what the longer term outcomes are for orthoses vs no treatment?
  14. markjohconley

    markjohconley Well-Known Member

    Goodaye Robert Isaacs, small typo? intra-articular?
  15. Am I missing the point? Since when did an inter-metatarsal angle "15<" define hallux valgus?
  16. Since some genius decided that people with no relevant experience or knowledge whatsoever got put in charge of micromanaging services and started demanding arbitary criteria and horribly oversimplified definitions in order that they can pretend that the decisions they make are be rational as opposed to the ill informed SWAG s they clearly are based on whoever can produce the proposals they understand and whatever internal political horse trading has gone on to decide who does what for how much money.

    World class comissioning for a brighter future.
  17. It might be stating the obvious, but you can have a 1-2 inter-metatarsal (IM) angle of whatever you like, without any deviation of the hallux on its metatarsal or even a varus deviation of the hallux on its metatarsal. Therefore, the 1-2 IM angle cannot be used as a determinant of hallux valgus in isolation:bang:. Moreover the flow chart actually has the symbol "< "which means less than. SO what they are saying is that a 1-2 IM of less than 15 degrees = hallux valgus. This, to be frank, is a load of old bollocks. I suspect what they were thinking of was a hallux abduction angle of >15 degrees, which is a common criteria to define hallux valgus.:bash: Similar, but not the same :deadhorse:

    P.S. in my crazy "old fashioned" world, surgical intervention should be a last resort, to be employed when conservative management has failed. Not an option based on a flow chart for "bursitis (true bunion)". ANd lets face it, until they pulled the Cochrane on hallux valgus from the website because it was "out of date" it stated that 1/3 of patients were dissatisfied post-operatively...
  18. What's that you say? Try a relatively inexpensive and low risk intervention on everyone before trying a pricey and risky one? :deadhorse:

    You crazy man. Next thing you'll be suggesting that nobody should have double neurectomies (2-3 and 3-4) before first exhausting all the non surgical options. Or that 23 year old's should probably avoid such neurectomies, especially when thrown in as an "oh and we'll also" when they get their asymptomatic HAV operated on.

    If we're feeling pedantic about the hallux valgus thing it might also be worth mentioning that hallux valgus is a frontal plane deformity and thus nothing to do with IM or even hallax abduction angle anyway. Or that degree of deformity need not correlate to degree of pain. Or that you can have hallux abduction without much IM angle. Or that the situation in the lesser toes (overcrowding, over-riding or whatever) is also significant. Or that this chart does'nt even MENTION 1st ray dorsiflexion.

    Or in fact that each patient is individual and should be considered on a case by case basis, not crammed into some box on a chart. :deadhorse::bang::bang:

    Private practice looks better each week (shut up Harland, no one likes a smartarse). The NHS lurches further into irrationality each day.
  19. Pod on sea

    Pod on sea Active Member

    I agree that each patient should be considered on a case by case basis, maybe private practice allows that more than NHS. Private practice doesn't come with all the politics/micromanagement but it has it's headaches! Patients want justification for spending their money on orthoses/ accommodative footwear (quite rightly). The more clearly we can explain our rationales the happier the patient is.
  20. G Flanagan

    G Flanagan Active Member

    I think the problem here is that most medics (including some orthopods) class Hallux (abducto) Valgus as

    1) metatarsus primus varus ie increased IM angle

    2) and the true hallux valgus ie abduction and valgus rotation.

    They dont understand that the term hallux valgus actually just means the movment of the hallux and include the deformity of the 1st ray in its meaning.

    To be honest a lot of Podiatrists also dont understand this, judging on the referrals our department recieves (Pod Surg).

    To be fair though, the majority of corrective hallux valgus surgery is based on the IM angle. In reality most people get an akin osteotomy of the proximal phalanx as an adjunct without charting PASA and DASA

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