There are a few subtle issues here. At first glance this foot looks half-way decent but upon further observation you should note the subtle drift of all of the toes. In the foot, the toe that delineates abduction and adduction of the toes is the 2nd toe. The 2nd toe is considered the anatomic middle of the digits and forefoot. Any toe or movement that moves away from the 2nd toe is abduction and any movement towards the 2nd toe is adduction. This is obviously different than in the hand where the 3rd digit is the reference digit.
In this foot, look at the shape of the 2nd and even the 3rd digit, they have a curve to them. Remember, form follows function and the dead give away here is that the hallux (the big toe) is drifting into adduction towards the 2nd digit. This is referred to as early hallux valgus and it is accompanied by early evidence of a bunion at the medial foot at the metatarsophalangeal joint. When the shaft of the hallux is not in line with the shaft of the metatarsal long bone we get the angulation between the two causing the hallux valgus. This is often from excessive pronation (either rearfoot, midfoot and/or forefoot) that collapses the tripod, splays the distal MET head via its dorsiflexion, and the development of complicated long and short hallux flexor muscle dysfunction as well as abductor hallucis (transverse and oblique head) disfunction further driving the hallux pull medially. When the distal toes are engaged on the ground and there is still forefoot pronation occurring through the medial tripod support, the toes will be forced into a twist or spin, and in time you will get toes that appear drifted or windswept like these toes appear. A similar phenomenon occurs at the lateral foot and a Tailor’s bunion begins to occur there as the forefoot begins to widen as the MET heads separate and the toes funnel medially (often provoked to do so by pointed footwear).
We can also see the 4th and 5th toes curl under from the probably weak lateral head of the quadratus plantae thus encouraging unopposed oblique pull of the long flexors of the digits (FDL). See this post here for an explanation of this phenomenon.
This is a fairly typical foot that we see in our practices. This is not a far-gone foot but one has to catch this foot at this stage or it is rather difficult to resuscitate back to a healthy foot. Like a spinal scoliosis, once a bunion and hallux valgus gets too far, it becomes an issue of symptom management rather than repair. Hallux abduction must be retaught, tripod skills must be retaught, intrinsic foot muscle strength must be regained as well as strength and endurance of the tibialis anterior and toe extensors to help raise the arch again and control pronation. Sometimes a temporary orthotic can help the person to passively regain some degree of competent tripod while homework earns the changes. In some cases, an orthotic needs to be a permanent intervention if tripod stability cannot be adequately achieved. But, we never give up and neither should you or your client, amazing things can happen over long periods of time when correction is forced.
There is plenty of life left in this foot, but you have to get to it quickly and get them in lower heeled shoes if tolerable and ones with a wider toe box. Support the midfoot with an orthotic or built up foot bed, if necessary, but don’t leave it there. It is a crutch, and even crutches are intended to be put aside at some point.
Shawn and Ivo, The gait guys
The Gait Guys
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