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HALLUX RIGIDUS: Myths and Misconceptions

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HALLUX RIGIDUS: Myths and Misconceptions BIOMECHANICS OF HALLUX RIGIDUS: Myths and Misconceptions Douglas H. Richie, Jr., D.P.M. Clinical Associate Professor, Department of Applied Biomechanics, California School of Podiatric Medicine Seal Beach Podiatry Group Inc [email protected] Hallux Limitus and Hallux Rigidus: Exploring the Myths and Misconceptions Douglas H. Richie, Jr. D.P.M. Seal Beach, California [email protected] Associate Professor of Podiatric Medicine, Western University of Health Sciences Adjunct Associate Professor of Clinical Biomechanics, California School of Podiatric Medicine, Oakland CA Douglas H. Richie, Jr. D.P.M. Seal Beach, California [email protected] Doug Richie D.P.M. gratefully acknowledges the Associate Professor of Podiatric Medicine, support and friendship of Western University of Health Sciences Paris Orthotics Adjunct Associate Professor of Clinical Biomechanics, California School of Podiatric Medicine, Oakland CA For lecture notes: www.RichieBrace.com www.richiebrace.com LIMITATION OF RANGE OF MOTION OF THE 1ST MTPJ Hallux Flexus : Davies-Colley (1887) Hallux Rigidus: Cotterill (1887) Hallux limitus: Hiss (1931) Functional Hallux Limitus: Laird (1972) MYTHS AND MISCONCEPTIONS ABOUT HALLUX RIGIDUS Normal range of motion of the 1st MTPJ 1. A minimum of 60 degrees of dorsiflexion of the hallux on the 1st Met is required for normal gait (True or False?) Reports of clinical measurements of ROM of 1st MTP: 65-110 Degrees Dorsiflexion (Buell, Hopson, Joseph, Mann, Shereff) Reports of ROM during gait: 50-90 degrees Dorsiflexion (Buell, Hopson, Johnson, Milne, Sammarco) Question #1 MYTHS AND MISCONCEPTIONS ABOUT HALLUX RIGIDUS Normal range of motion of the 1st MTPJ Clinical assessment of ROM of the 1st MTPJ “Relationship Between Clinical Measurements and Motion of the First Metatarsophalangeal Joint During Gait” Nawoczenski et al. JBJS 81-A, pp 370-376, March, 1999. Electromagnetic tracking to determine 3-D motion of the hallux relative to the 1st Metatarsal 33 subjects Four Clinical Tests for ROM of 1st MPJ compared to actual ROM of 1st MPJ during gait Clinical Tests Active ROM-weight bearing Passive ROM- weight bearing Passive ROM-non weight bearing Heel Rise test Results Walking ROM dorsiflexion: 42 degrees Heel Rise ROM dorsiflexion: 58 degrees Passive ROM non-wt bear: 57 degrees Passive ROM dorsiflexion: 37 degrees Active ROM dorsiflexion wt.bear: * 44 degrees “Measurement of the active range of motion with the subject weight bearing may be a more appropriate choice for a clinical test because the mean value for dorsiflexion more closely matched that during gait.” “Relationship Between Clinical Measurements and Motion of the First Metatarsophalangeal Joint During Gait” Nawoczenski et al. JBJS 81-A, pp 370-376, March, 1999. Biomechanics of Hallux Rigidus Key Point #1: Patients do not use all of the range of motion available in their pedal joints during gait. Measuring total range of motion of the 1st MTP does not predict how much motion the patient actually needs or uses during gait. Research Method Subject criteria: o 6 people o 2 males o 4 females o 12 feet o No foot pain or any limited motion at the first mtpj o Treadmill running and walking Preliminary Results - Walking SUBJECT MAX MIN DIFFERENCE EP-R 176.54 153.11 23.43 EP-L 166.78 140.03 26.75 MA-R 174.18 147.45 26.73 MA-L 176.67 138.46 38.21 JJ-R 175.99 140.73 35.26 JJ-L 179.44 134.35 45.09 JL-R 176.72 149.19 27.53 JL-L 162.42 132.46 29.96 TS-R 169.89 137.69 32.2 TS-L 167.56 121.11 46.45 ZY-R 175.3 134.11 41.19 ZY-L 176.72 136.69 40.03 AVERAGE 34.4025 Preliminary Results - Running SUBJECT MAX MIN DIFFERENCE EP-R 170.45 156.87 13.58 EP-L 174.15 143.28 30.87 MA-R 174.86 147.6 27.26 MA-L 175.75 149.07 26.68 JJ-R 172.52 152.94 19.58 JJ-L 175.38 144.83 30.55 JL-R 177.22 155.48 21.74 JL-L 174.85 151.16 23.69 TS-R 172.86 140.83 32.03 TS-L 168.02 138.5 29.52 ZY-R 171.75 136.63 35.12 ZY-L 173.08 141.49 31.59 AVERAGE 26.8508 Statistical Significance o Standard Deviation o Walking = 7.7575 o Running = 6.1785 o Ttest p-value = 0.002358 Walking Running When running , compared to walking: - the ankle flexors (Triceps, FDL, FHL) fire earlier -ground reaction forces in FF peak earlier -Early, greater contraction of FHL limits dorsiflexion of the 1st MTP When running the Flexor Digitorum Longus and the Flexor hallucis longus fire earlier and resist DORSIFLXION of the digits to a greater degree than during walking. The flexor hallucis longus can be a natural splint to resist dorsiflexion of the 1st MTP. Hallux Rigidus: Role of Soft Tissue Constraints -plantar aponeurosis -flexor hallucis longus Sectioning of the plantar fascia results in an increased dorsiflexion of the 1st MTP by 9.8 degrees. Harton FM, Weiskopf SA, Goecker RM. Sectioning the plantar fascia. Effect on first metatarsophalangeal joint motion. J Am Podiatr Med Assoc 2002;92:532-6. Biomechanics of Hallux Rigidus Key Point #4: Dorsiflexion of the 1st MTP is restricted by tension in the soft tissues around the joint: Plantar aponeurosis, FHL tendon, FHB and other sesamoid anchors. Procedures which improve hallux rigidus do so by decompressing the joint, which relaxes tension on these structures. MYTHS AND MISCONCEPTIONS ABOUT HALLUX RIGIDUS Normal range of motion of the 1st MTPJ Clinical assessment of ROM of the 1st MTPJ Classification of Grades of Disease of Hallux Rigidus Role of Metatarsus Primus Elevatus First Ray Hypermobility The term “hypermobility” was first used to describe the mechanical function of the first ray in 1935 by Dudley J. Morton, Professor of Anatomy, Columbia University, in his classic treatise, “The Human Foot”, on the evolution, physiology, and functional disorders of the foot Root et al Extensively Discussed First Ray Hypermobility in 1977 “Hypermobility is any motion occurring at a joint in response to forces which are interacting at a joint at a time when the joint should be stable under such forces” “Hypermobility of the first ray is a state of abnormal 1st ray instability that occurs while the forefoot is bearing weight” How do we measure “hypermobility” of the First Ray? Measuring “First Ray Mobility” Examiner may use an estimated amount of manual force on first metatarsal head to measure “first ray mobility” Root ML, Orien WP, Weed JH, RJ Hughes: Biomechanical Examination of the Foot, Volume 1. Clinical Biomechanics Corporation, Los Angeles, 1971. 2 mm Plane of Plane of left thumbnail right thumbnail Position of Ankle Can Affect First Ray Mobility Plantarflex: Increase mobility Dorsiflex: Decrease mobility Grebing, BR; Coughlin, MJ: The effect of ankle position on the exam for first ray mobility. Foot Ankle Int. 25:467– 475. Devices which measure First Ray ROM Glasoe, WM; Grebing, BR; Beck, S; Coughlin, MJ; Saltzman, CL: A comparison of device measures of dorsal first ray mobility. Foot Ankle Int. 26:957– 961. Kim, JY; Keun Hwang, S; Tai Lee, K;Won Young, K; Seon Jung, J: A simpler device for measuring the mobility of the first ray of the foot. Foot Ankle Int. 29:213 – 218. Klaue, K; Hansen, ST; Masquelet, AC: Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relation to hallux valgus deformity. Foot Ankle Int. 15:9– 13. Glasoe and coworkers have done considerable research on developing a special apparatus that applies a precise amount of loading force on the first metatarsal head to determine the amount of “first ray mobility” Glasoe WM, Yack HJ, Saltzman CL: The reliability and validity of a first ray measurement device. Foot Ankle Int. 21:240-246, 2000. Glasoe WM, Allen MK, Saltzman CL, et al: Comparison of two methods used to assess first ray mobility. Foot Ankle Int. 23:248-252, 2002. Glasoe WM, Allen MK, Ludewig PM, Saltzman CL: Dorsal mobility and first ray stiffness in patients with diabetes mellitus. Foot Ankle Int. 25:550-555, 2004. Pronation of the subtalar joint does not appear to be linked to “hypermobility” of the 1st ray, or to reduced range of motion of the 1st MTP. Hypermobile First Ray? 82 Asyx Adults Dorsiflexion ROM of 1st Ray measured with “mobility device” as described By Glassoe et al. 3 subgroups defined: hypomobile, normal and hypermobile Plantar pressures and hindfoot kinematics measured during walking Cornwall MW, McPoil TG, Fishco WD, et al: The influence of first ray mobility on forefoot plantar pressure and hindfoot kinematics during walking. Foot and Ankle Int27:539-547, 2006. RESULTS “Based on the findings of this study, it appears that a person with a hypomobile first ray does not demonstrate increased plantar pressure or force under the first metatarsal head or diminished hindfoot eversion during walking. Conversely, the foot with a hypermobile first ray does not show increased pressure and force under the second metatarsal head along with increased hindfoot eversion during walking.” “Hypomobile” First Ray had significantly more hindfoot eversion compared to the “normals” and “hypermobile” first rays Cornwall MW, McPoil TG, Fishco WD, et al: The influence of first ray mobility on forefoot plantar pressure and hindfoot kinematics during walking. Foot and Ankle Int27:539-547, 2006. Is Metatarsus Primus Elevatus equivalent to Hypermobility of the First Ray? Coughlin MJ, Shurnas PS: Hallux Rigidus: Demographics, Etiology, and Radiographic Assessment. Foot & Ankle International/Vol. 24, No. 10/October 2003, pp 731-743. Hallux rigidus was NOT associated with: MPE First ray hypermobility Increased first metatarsal length Achilles or gastrocnemius tendon tightness Abnormal foot posture Coughlin MJ, Shurnas PS: Hallux Rigidus: Demographics, Etiology, and Radiographic Assessment.
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