1st Ray Flashcards
what is the inferior surface of the 1st MT head grooved for?
articulation with the sesamoids
what are the sesamoids embedded in
the plantar plate
Sesamoids divide the plantar plate into what ligamentous regions?
- metatarsosesamoid ligaments (medial and lateral)
- phalangeosesamoid ligaments (medial and lateral)
- intersesamoid lig
what forms the sesamoid apparatus?
- tendon of FHB
- tendon of abductor hallucis
- conjoined tendon of adductor hallucis
- sesamoids
- plantar plate (includes sesamoid ligaments)
what bones does the 1st ray consist of
First MT and 1st cuneiform
what bones does the 1st ray articulate with
navicular, 2nd MT base and intermediate cuneiform
describe the motion of the 1st ray
uniaxial but triplanar
where does the axis of the 1st ray pass?
anterior, lateral, plantar to posterior, medial and dorsal
does the 1st ray provide for supination/pronation
NO, axis is directed opposite to the joints that provide for supination/pronation
the 1st ray is deviated:
- – from the sagittal plane
- – from frontal plane
- – from transverse plane
45
45
9
what type of motion occurs at the 1st ray
equal dorsiflexion/inversion and plantarflexion/eversion
what are some planal dominance of the 1st ray
- sagittal plane deformity
- dorsiflexed 1st ray
- congenital dorsiflexed 1st ray (metatarsus primus elevatus)
- acquired dorsiflexed
are typically bilateral and usually asymmetric
what are etiologies of a dorsiflexed 1st ray
- compensated RF varus
- FF supinatus
- abnormal STJ pronation (PL tendon looses its pull allowing the 1st ray to dorsiflex)
- spasm of the TA
- paresis or paralysis of the posterior tibial
- compensated FF varus
- iatrogenic
- trauma
what are clinical observations that are symptomatic of a dorsiflexed 1st ray?
- hallux limitus
- dorsal prominence
- hyperkeratotic lesions submet 2 and plantar aspect of the IPJ of the hallux
- during gait the STJ pronates and the calcaneus everts during propulsion
what are etiologies of a plantarflexed 1st ray
- congenital
- uncompensated RF varus
- FF valgus
- peroneal longus spasm
- paralysis of the TA and gastroc/soleus complex
- iatrogenic
what are clinical observations of a plantarflexed 1st ray
- hyperkeratosis submet 1 and 5
- compensation causing STJ supination
- acquired pes cavus foot type
plantarflexed 1st ray treatment
NSAIDs, analgesics
Orthotics (treat biomechanic abnormaility, 1st ray cut out to accommodate the 1st MT and sesamoids)
Surgical osteotomy
what is hallux limitis
- deformity of the 1st MPJ
- base of the proximal phalanx of the hallux is subluxed plantarly on the 1st MT head
- hallux is unable to move on the dorsum of the 1st ray
in younger patients with hallux limitus, you usually see
an exostosis
in older patients with hallux limitus, they usually present with
DJD of the articular surface
etiologies of hallux limitus
- hypermobility of the 1st ray
- excessively long 1st ray
- dorsiflexed 1st ray
- arthritis
- trauma
- osteomyelitis/septic joint
- paralysis of PL or spasm of TA
clinical features of hallux limitus
- 1st MT head is square in shape
- boney proliferation of the 1st MPJ
- compensation at the joint most distal AND most proximal
- tendonitis of the EHL
- decrease length of propulsion
- hyperkeratosis at the plantar aspect of the IPJ of the hallux
- trauma to the toenail
what is stage 1 of hallux limitus?
No DJD on x-ray
Normal ROM on non-weight bearing
No pain at end ROM
what is stage 2 of hallux limitus?
Pain at end ROM
Flat 1st MT head
Dorsal exostosis and periarticular lipping
what is stage 3 of hallux limitus
Crepitus on ROM
Joint space narrowing
Osteophyte formation
Increase flattening of the 1st MT head
what is stage 4 of hallux limitus
- obliteration
- osteophyte fragmentation
- minimum ROM/total ankylosis
what is the Drato, Oloff and Jacob Classification
Stage 1 - Pre-hallux limitus
Stage 2 - Structural adaptation
Stage 3 - Bone destruction
Stage 4 - End stage
what is functional hallux limitus
-limitation of the dorsiflexion of the 1st MPJ available during the stance phase of gait
is pain present upon examination of a functional hallux limitus
no (only a problem when ambulated)
what is required for treatment of a functional hallux limitus
- recognize etiological factors
- examine the LE and foot
- examine both weight-bearing and non weight-bearing ROM
- examine gait analysis
what is the conservative treatment for functional hallux limitus
NSAID
Steroid medication/oral or intra-articular injections
Orthoses - functional hallux limitus
Shoe gear - high toe box, steel shank, lower heel height, proper shoe size, avoid heel lifts
HAV deformity occurs in what planes?
transverse AND frontal plane
what kind of deformity is HAV
Progressive subluxation of the 1st MPJ during the propulsive phase of gait
what are the pathomechanics of HAV
- hypermobile 1st MT head inverts relative to the hallux
- a valgus subluxation occurs at the hallux at the 1st MPJ
- base of the proximal phalanx of the hallux subluxes laterally on the 1st MT head
- hallyx abducts on the 1st MT head
- the 1st ray subluxes at its base and the 1st MT adducts
Etiologies of HAV
- hypermobile 1st ray
- rheumatoid arthritis (system disease)
- neuromuscular disease
- iatrogenic
- abnormal STJ pronation
what occurs during Stage 1 of HAV deformity
- lateral subluxation of base of proximal phalanx
- minor lateral sesmoid displacement
lateral subluxation of base of proximal phalanx is only evident in what kind of x-ray
weight-bearing AP views
what occurs during Stage 2 of HAV deformity
- abduction deformity of the hallux
- hallux presses against 2nd toe
- medial bump
- sesmoids shift laterally
what occurs during Stage 3 of HAV deformity
- increased widening of the foot
- increase intermetatarsal angle
- tibial sesmoids are lateral to the 1st MT head
- mononeuritis is a common complaint
what occurs during Stage 4 of HAV deformity
- dislocation or major subluxation of the hallux
- overlapping 2nd digit
- frequently seen in conjunction with rheumatoid arthritis
- apropulsive gait
rate of development of HAV depends on
- extent or amount of abnormal STJ pronation
- size of the FF adducts angle
- extent of calcaneal eversion
- extent of STJ an MTJ subluxation
- extent of chronic inflammation at the 1st MPJ
what are other factors of HAV
- inclination angle of the STJ (, more calcaneal eversion with STJ pronation)
- excessive angle and base of gait
- absence of a propulsive period during stance phase
- obesity (may widen the base of gait)
- length of stride (if there is pronation during propulsion)
- hard flat terrain (can cause more abnormal pronation)
- abnormal fitting shoe gear
treatment of HAV
conservative - NSAIDs, steroid injection
- change in shoe gear*** (MUST DO THIS)
- orthoses
what is juvenile HAV deformity
- onset may occur at any age
- Root - “onset occurs when the child develops a propulsive gait (HAV is acquired)”
- a deformity exists in an individual 20 years-old or younger due to growth and remodeling of articular cartilage
factors associated with juvenile HAV
Metatarsus Adductus Pes Planus Ankle Equinus Hypermobile First Ray Neurological Disorders Juvenile Rheumatoid Arthritis
treatment of juvenile HAV
- conservative
- splints
- bunion shield
- shoe
- orthoses
what are the 2 surgical treatments for juvenile HAV
Delay surgery until skeletal maturity has occurred to avoid injury to the epiphyseal structures
Perform surgery before adaptive changes has created permanent alterations of structures
what is splay foot
- progressive abnormal transverse plane spreading of the MT
- an abnormally large intermetatarsal angle btwn the 1st and 2nd and the 4th and 5th MT
what are etiologies of spay foot
- abnormal STJ pronation
- subluxation of the rays at their basal joints which articulate with the navicular, cuboid and with each other
pronation in a splay foot can cause
- decrease transverse arch
- talus is displaced medially and plantarly
- if MT primus adducts and subluxation of the 5th ray is present, there is an increase in the angle btwn the 1st and 2nd MT and 4th and 5th MT
- the entire MT will become less stable to vertical GRF and ligaments become stretched
what are clinical features of Splay foot
- wide FF
- prominent HAV and Tailors bunion
- digital deformities
what is the normal IM angle of MT 1 and 2
7-9