Hallux Limitus, anyone?

-This woman presented to our office this morning with a capsular interposition procedure that didn’t go so well (placing material between the distal first Ray and first phalanx to create cushioning and increased hallux dorsiflexion). 

-She has opted for conservative treatment for the time being. We are working on decreasing inflammation to see if we can increase plantar flexion of the distal aspect of the first Ray. She currently has 0° in her shoes and 5° when we planter flex the distal first. 

-Exercises included the lift/spread/reach exercise, short foot exercise, toe waving and one leg standing. 

-We will keep you posted. 

-Look for her x-rays tomorrow

#FootPain #Hallux#halluxlimitus #halluxrigidus #1stmtp #1stmetatarsalphalangealjoint #Gait #ClinicalEvaluation

1st MTP Pain? The Biomechanics of the Big Toe...

Remember the rockers? We have done a series on this in the past. Remember there are three: heel, ankle and forefoot. We are going to concentrate on the forefoot today.

As a reminder, forefoot rocker occurs at the 1st metatarsal phalangeal joint (big toe knuckle) as the tibia progresses over the forefoot during forward movement. You NEED 50 degrees to do this competently; you SHOULD have 65 degrees. When you don’t, you have a condition called hallux limitus. This could be from a number of reasons, from overpronation in the mid foot, to a bunion, to faulty firing patterns of the muscles which help to descend the 1st ray (the extensor hallucinations brevis, the peroneus longs and the short flexors off the toes). Pretty much, ANYTHING that causes a dorsal and posterior shift of the 1st MTP axis will cause limited forefoot rocker.

So, the question is, “Do you know where 1st 1st MTP pain may be coming from? How familiar are you with the mechanics of that joint?”

Take a few minutes to review it in this video with Dr Ivo Waerlop of The Gait Guys.

#gait, #gaitanalysis, #1stmtp, #forefootrocker, #thegaitguys,

Do you really understand what it takes to control the 1st Metatarsal during loading ?

Do you have dorsal (top) foot pain, at the peak of the arch? Think you are tying your shoes too tightly and that is the cause? Do you have pain over the dorsal or plantar mid foot on heel rise or jumping/landing or going up stairs ?

Just because you raise your heel and load the ball of the foot does not necessarily mean you have adequately plantarflexed the 1st metatarsal and loaded it soundly/stable with the medial tarsal bone. Heel rise, and thus loading onto the medial foot tripod, must be met with ample, stable, durable, 1st metatarsal plantarflexion and the associated medial tarsal bones. Also, without this, loading of the sesamoids properly cannot occur, and pain may ensue.

The first ray complex can be delicate in people who are symptomatic. In some people who do not have a good tibialis posterior-peroneus sling mechanism working harmoniously, in conjunction with a competent arch tripod complex to achieve a compentent arch complex (ie, EDL, EHL, tib anterior and some of the other foot intrinsics) this tarsometatarsal interval can become painful and instead of the 1st ray complex being stable and plantarflexing as the heel departs and the 1st ray begins taking load, it may not do so in a stable plantarflexed posturing. In some people it can momentarily dorsiflex as the arch subtly collapses (when it should be stable and supinated in heel rise).

"Subtle hypermobility of the first tarsometatarsal joint can occur concomitantly with other pathologies and may be difficult to diagnose. Peroneus Longus muscle might influence stability of this joint. Collapse of the medial longitudinal arch is common in flatfoot deformity and the muscle might also play a role in correcting Meary's angle."-Duallert et al

Soon, I hope to show you a video of how to watch for this problem, how to train it properly, how we do it in my office.
Dr. Allen

Reference:

Clin Biomech (Bristol, Avon). 2016 May;34:7-11. doi: 10.1016/j.clinbiomech.2016.03.001. Epub 2016 Mar 10.  The influence of the Peroneus Longus muscle on the foot under axial loading: A CT evaluated dynamic cadaveric model study. Dullaert K1, Hagen J2, Klos K3, Gueorguiev B4, Lenz M5, Richards RG6, Simons P7.

https://www.ncbi.nlm.nih.gov/pubmed/27015031

Who’d a thought? Can someone make an “app” for that?

Interesting study that we just found out about in the June 15th LER journal titled “Patients with ankle instability respond to auditory feedback by changing gait”

In this study they put a sensor under the head of the 5th metatarsal in 10 folks with chronic ankle instability that would emit a sound in respose to excessive lateral ankle pressure. They were told to “walk quietly” and not let the beeper beep. After a short time, the people in the study were able to walk with decreased pressures in the lateral forefoot, in addition to the midfoot and central forefoot. EMG showed increase in peroneal and medial gastroc activity.

Interesting implications and also some questions.

This study shows that auditory feedback can alter behavior and gait. Is this a good thing? We suppose this depends on what you are trying to accomplish and does it ultimately benefit the patient?

this sensor could be made into an “app” that has some cool rehabilitation implications. Imagine a moveable sensor or multiple sensors that could track patterns over time and plot them for you? The auditory could be used to discourage some bevaiors/characteristics of gait and the “tracking” feature could provide progress information. Or maybe is it hooked up to some of your favorite music and it stops playing when you are not weighting appropriately. Wondering if your patient is loading the head of the 1st metatarsal? This could provide some feedback.

Check it out:

Donovan l, Hart JM, Saliba S et al. Effects of an auditory feedback device on plantar pressure in participants with chronic ankle instability. Med Sci Sports Exerc 2015; 46(5 suppl); S104