Possible FHL

[TimVS]

Always worry a bit when patients come in with a history of different orthoses. Anyway, here it is:

Woman in her 4os with long hist of bunion pain BL. She used to walk 30 miles a day now finds it painful to walk any distance. Also admits to BL hip pain. Has had 2 prev pairs of orthoses. 1st apir too hard and uncomfortable, threw them away. 2nd pair soft EVA type devices, NHS chairside. (seen these)Improved symptoms initially but came back after a while. Shoes wear quickly on the outside?

WB moderate pronation BL FPI +5 LF, +7 RF with flattening of arches. Supination resistance is high, unable to passively DF Hx. R shoulder lower.

NWB LF valgus, RF varus, BL Hx limitus. HK sub 5th MHs and apex 4th and 5th toes (adductovarus)

Gait (here is where it get's interesting) Here are the scans hopefully:





Gait is fast with RF abducting, left knee internally rotating. R shoulder and pelvic drop. Flattening of arches but minimal calc eversion. RF is faster with early heel lift on the scans. Minimal Hx pressures BL, (I know the left scan shows 1st met pressures, bu the others didn't) high pressures Hx and 2/3 MHs. Also high pressures RF MTJ at midstance may indicate MTJ collapse. The overall picture is of FHL? What I can't work out is the lateral loading given ther are no signs of supination on the scans, visual gait or static WB. Unless she is rolling out laterally to get around the functionally locked Hx?

At the moment I'm thinking around a soft device 3/4 with minimal posting and probably a 1st ray c/out, although I'm umming and ahhing about that still. Might try without and add it later.

What think you?

[robertisaacs]

More pretty pictures. I look forward to the replies of the more educated so i can learn something. I feel like a caveman examining a bughatti. I can see its impressive i just don't fully know why. "Ugg. Mammouth with shiny metal skin and twin independant engines with 500 HP/ton and no tusks, urgh."

My immediate thought is that if the Soft EVA (i presume you meen freelans) helped and the rigid did not you've got to throw malignant hypertonia into the stew. Therefore anything which feels rigid or which the patient does not "beleive in" will be doomed.


As far as the lateral loading my caveman logic is as follows. Lateral wear on shoes and lateral pretty red bits (urgh) make me wonder if she is heel striking and loading laterally using the presumably significant muscle power you get when you used to walk 30 miles a day. You might well not see this as supination as it might be a kinetic effect rather than a kinematic one. At some point during the forfoot loading, possibly when the 5th met loads the foot pivots off the 5th met onto the 1st IPJ (UUUUUUURG, saber tooths come!). Basically i'm imagining the foot as a triangle with the mass transfering from heel to 5th met to 1st ipj in that order. Do not pass go, do not load 1st mpj, do not collect 40% of Metatarsal load on the 1st MPJ.

I would be looking to copy what worked in more perminant materials as a first step. Freelans lose their integrety rather fast. I wonder if thats why they stopped working. Depends what mods they had used.

If she has got a good ole fashioned FHL just like Ma use to bake then what you suggest with a 3/4 with a met head cut out in something soft would do real nice.
If the foot IS loading laterally and pivoting onto the 1st ipj then a soft (lunarsoft with a 3mm poron cover for EG) full contact SD FFO with a sagital plane rocker with the medial distil extremity to the the distil part of the 1st met and the medial just proximal to the proximal extremity of the 5th (so its angled off so it tips the foot laterally) might be the path to joy.

Oh and I'll bet you a beer she has a laterally deviated STJA.

I don't understand the COPP. How come it stops before the 1st met loads, should it not vere to the medial at that point? (uuuuuuuurg 16 valve engine and twin turbochargers)

Anyway, off to kill a bison with my teeth.

Regards
Ug.

[dtt]

Hi Tim

This is screaming HIP dysfunction at me ??

Dropped right shoulder /pelvis abducted right leg internally rotated left tibia , bilateral hip pain , early heel lift ?

How about some work on piriformis and gluteus medius and then gastroc soleus complex for starters and then rescan to see what difference that has made ?

The scan you have put up really does not tell us much without the data profile and graph to analyse how the foot is functioning and the timing etc .

I have a problem putting mine up as every scan contains the Pt details but I have printed one off (details blanked out) for next weeks seminar to discuss.

Can I ask if the patient is facing away from you and you are directly behind her, how many toes can you see ?? ( should be 5 / 4th) .

I would guess certainly on the right foot you will see most if not all ?? The left a bit less I would guess.

A forefoot pronator ?? the problem footwise being in the MTJ and subsequently 1st ray hence the lack of action in the 1st mpj.

I think Robert has it right with his triangle theory ( I prefer levers from rearfoot to midfoot to forefoot ) this one in going belly up at the midfoot

I had a runner in a few weeks ago with a virtually identical scan and I got a second opinion from the new clinical lead for the orthotic group as I was unsure of what I was seeing as well.

We did a 2mm semi rigid running orthotic with an extended long arch, 2mm intrinsic forefoot posting, bilateral met pads , and 1st ray cut outs which to date ( 1 month) has got him back running and pain free.

That was after I sent him to a chiropractic /physiotherapist ( dual degree qualified) colleague to work on his right hip.

As I said much of my theory is guess work because I'm not sure of the boundaries of your pressure plate system and if more information is available but I hope it helps

(And Robert I've got colours upon colours for you next week !! ;D)

cheers M8's
D

[davidsmith]

Tim

You wrote
"What I can't work out is the lateral loading given ther are no signs of supination on the scans, visual gait or static WB. Unless she is rolling out laterally to get around the functionally locked Hx?"


Lets look at what thing could lead to lateral foot loading.

1) Valgus f/foot
2) non compliant plantarflexed 1st ray
3) Hypotonicity or weak Peroneals / Hypertonicity Ant Tibialis
4) Early firing of Peroneous Longus with compliant 1st ray becoming functionaly non compliant.
5) Uncompensated rearfoot varus
6) Uncompensated f/foot varus
7) Genu / tibial Valgum
8) Uncompensated Genu / tibial Varum
9) Toeing in (antetorsion, retroversion, internal malleolar torsion)
10) forefoot equinus
11) Ankle equinus
12) Vertical Talus (rocker Foot)
13) Talipes EquinoVarus
14) Metatarsus adductus
15) Abducted foot placement angle with ref to 5 & 6
16) Short leg on ipsilateral side
17) Internally rotated hip
18) FncHL
19) Hallux Limitus
20) Hallux rigidus
21) Antalgic response
22) wide base of gait
23) Balance problems (neurological (peripheral, CNS), vestibular, Occular)
24) Shoe wear
25) orthotic posting
26) Camber of the ground
27) STJ axis position
28) compliance of 5th ray

What one parameter might differentiate most of these possible aetiologies, in terms of visual or plantar pressure evaluation?

As Derek pointed out TIMING. Unfortunately your pressure map postings are not Dymanic and tell us little to nothing about timing of the lateral loading or any other loading times.

Its difficult to hazard a guess at a prescription with the available info but my best advice, especially as she is a keen walker, would be get her into a stiff soled rocker/toe spring shoe. This will reduce or eliminate dorsiflexing moments about the 1st MPJ and will reduce tissue stress and therefore reduce pain.
Generally to reduce FncHL then reduce 1st mpj plantar pressure (at the wrong time) while at the same time not increasing sub hallux pressure.
This requires a reduction in Plantar Fascia tension from early mid stance. This can be achieved by not allowing the Medial Longitudinal arch to extend / lower past a certain length/height or by reducing plantar reaction force on the medial foot.
At heel lift the dorsiflexing moments about the TNJ or 1st CNJ should be reducing. If at this time the arch is low and the plantar pressure sub 1st MPJ is low and sub hallux pressure is high then dorsiflexing moments about the 1st ray will be increasing and so FncHL will exist.

Read: The Effects of Hallux Limitus on Plantar Foot Pressure and Foot Kinematics During Walking. Gheluwe B, Dananberg HJ, Hagman F, Vansteen K (JAPMA 96 5 425-436 2006)

Read also Dananberg papers on sagital plane progression and FncHL

Sagittal Plane Biomechanics HOWARD J. DANANBERG, DPM* JAPMA 90 2000
Gait style as an etiology to chronic postural pain. Part I. Functional hallux limitus / Part II. Postural compensatory process
JAPMA 83 1993

Cheers Dave

[TimVS]

Phew!
Thanks David. As usual a comprehensive and detailed reply

I take your point about the scans. However the dynamic scans are embedded in the software and I have no idea how, or if, they can be displayed in a forum such as this. Blimey, I've only just worked out how to post piccies. Give me a break man! If I can work out how I'll do it next time ok

Right, onto the nitty gritty

This requires a reduction in Plantar Fascia tension from early mid stance. This can be achieved by not allowing the Medial Longitudinal arch to extend / lower past a certain length/height or by reducing plantar reaction force on the medial foot.

Sorry, don't understand this. Isn't the point that you want the 1st ray to plantar flex to facilitate Hx dorsiflexion?. Isn't the point of a 1st ray cut out to reduce plantar reaction force medially and thus allow the first ray to plantar flex? (Ugh, me no understand. Me no touched shiny obelisk yet)

Yep. hip and pelvic stability is a big factor here, and I'm getting that looked at. Agreed on the shoes, I'd already given her advice in that direction.

I'd love to look at those studies Dave, but my Uni doesn't have access to JAPMA. I'll have a peep at the abstracts though

Having looked at the above I have come to the conclusion that the lateral loading is mainly due to a compensatory response to offload the painful MPJs. Too simple? Well, maybe but so am I. I like the simple things in life. The casts are valgus so at the moment I am going for a soft device with a 1st ray cut out to facilitate Hx dorsiflexion.
See how it goes.

Shame we didn't have more time at the weekend. I could have shown you the dynamic scans then

[davidsmith]

Tim

You wrote
"Sorry, don't understand this. Isn't the point that you want the 1st ray to plantar flex to facilitate Hx dorsiflexion?. "(

Yes this is correct, I don't quite see what it is you don't understand?

Also wrote
"Isn't the point of a 1st ray cut out to reduce plantar reaction force medially and thus allow the first ray to plantar flex?"

That right, but to split hairs then; The point is not to reduce planar medial/1st mpj pressure but to reduce and increase it at the right times.
The real point is to stop plantar fascia extension beyond a certain length. This change in length/strain will equal a rise in tension/stress, which if we assume the Plantar fascia central band only plantarflexes the hallux thru its insertion into the proximal phallanx via the sesamoids, then equilibrium of forces and moments predicts that this will increase sub hallux pressure and so REDUCE sub 1st met pressure but will lead to FncHL.
This wiill happen because of two reasons, first the force x lever arm to the hallux is longer than to the 1st MPJ = increased dorsiflexion moments about the 1st ray. 2nd the lowered MLA means that the mechanical advantage of the 1st ray plantarflexors is reduced, therefore less plantarflexion moments about the 1st ray. In total this equals increasing dorsiflexion moments about the 1st ray. If the 1st ray is tending to dorsiflex then if we evaluate the the dynamics of the foot at the time of the early propulsive stage then we require the 1st ray to be plantarflexing in order to supinate the foot. When this happens the hallux is allowed to dorsiflex due to the low tension in the plantar fascia. As the foot goes into the propulsive stage there is a small extension of the plantar fascia (but extension of the MLA continues to decrese) until about 83% of the stance phase (my MSc research). This sequence is the requirement ot avoid FncHL and fits very well with Dananbergs paper on plantar foor pressures and Func hallux limitus.

The 1st met c/o or kinetic wedge allows the 1st ray to plantarflex early in the stance phase and so not be acted upon by GRF and therefore be dorsiflexed and so extend the PF. In the plantarflexed position the muscular attachment have greater advantage and can therefore more easily stabilise the 1st ray in this position.

Send me your email address and I'll send the papers including mine. You do have broadband I trust otherwise they will take hours to download. my email- [e-mail]

Cheers dave