L14 Hallux Valgus and PTT Flashcards
Hallux Valgus
chronic progressive deformity of first ray
lateral deviation of 1st toe, medial deviation of first metatarsal with some rotation
Causes of Hallux Valgus
genetic component
arthropathy: RA, gout, psoriatic arthritis
high heels and/or tight toe box (men who wear shoes w/wide toe box w/out high heel have HV, females wear high heels with tight toe box do not have HV)
Prevalence of HV
23% of population from 18 to 65
36% adults >65yo
more common in females
Hallux Rigidus
chronic progressive OA of the 1st MTP Joint. often shows up as bilateral
2.5% of persons > 50 yo
most common in females
most common form of arthritis in foot
Causes of HR
idiopathic
2/3 cases have family hx
trauma, RA
What will the exam include for HR and HV?
squat, stairs
observation
history
gait
AROM/PROM
balance
Goal for treatment of the midfoot
improve muscle performance for MLA dynamic stability and power generation
power is generated in midfoot
muscle atrophy accelerates after age 50 so it is important to address muscle weakness
Severe angles of foot
HVA = over 40°
Intermetatarsal angle = over 20°
Moderate to severe HV is associated with
reduced hallux plantar pressures and strength measures
Women with mild HV showed
significantly higher pressure under the hallux than controls
There is ____ force under the hallux for HV
reduced
Plantar Loading Post-op
remains altered 12 mo post-surgically
even with decreased pain and sufficient first MTP joint ROM
Loading in Hallux Rigidus
had significantly less push off
increased forefoot supination
no significant differences in plantar loading
1st MTP ROM did not improve post-op level. Exercising should being immediately post op
Overall summary of HV and HR plantar pressures
conflicting literature
assess relevance in each individual
maladaptive compensatory patterns may lead to increased pain
recruitment of peroneals
seated, lift lesser toes from floor while increasing plantar pressure under 1st met head
“keep arch up”
progress to BIL and SL heel rise, and with perturbations
Posterior Tibial Tendon Dysfunction
collapse of medial longitudinal arch of foot with continued progressive deformity of foot/ankle
most common cause of adult acquired flatfoot
Causes/RF of PTTD
idiopathic
obesity
age > 50 yo
inflammatory conditions-RA, psoriatic arthritis, spondylosing arthropathy
S/S of PTTD
insidious onset of edema/pain along post tib tendon
pain aggravated by standing, walking
pain is worse w/standing, high impact
unable to run
inability to push off, raise heel
What is the biomechanical reason for altered gait in PTTD?
inability to lock midtarsal joint and achieve rigid propulsion
Observation of PTTD
- asymmetric flat foot
- flattened medial longitudinal arch
- hindfoot valgus
- abduction of the midfoot on the hindfoot
- too many toes sign
- antalgic gait pattern
- decreased stride length, poor heel off
- tenderness along the distal aspect of post tib tendon
What compensates in PTTD?
anterior tibialis
toe extensors try to lift foot up by splaying toes
ROM of PTTD
- limited DF
- Subtalar and transverse tarsal jts are mobile in early stages
- loss of motion, midfoot becomes fized in late stages
MMT of PTTD
pf and inversion are still strong because of ant tib contribution
inability to perform a single leg heel rise, which is indicative of PTTD
Stage 1 of PTTD
tendon synovitis
no foot deformity, no arch collapse
Stage 2 PTTD
tendon pathology with or w/out synovitis
flat foot deformity
damage to spring lig and soft tissues
hypermobility
Stage 3 of PTTD
- tendon pathology with or w/out synovitis
- damage to spring, deltoid ligaments and soft tissues of foot
- fixed deformity w/forefoot abd and hindfoot valgus
Stage 4 PTTD
- tendon pathology with or without synovitis
- damage to spring, deltoid ligaments and soft tissues
- fixed deformity w/complete ankle valgus
Modifications for PTTD
weight loss, improving footwear, decrease repetitive loading
orthoses to decrease pain as an early intervention, also use eccentric strengthening
goal in stage 2 is to support arch and decrease valgus
Target muscles for Medial Long Arch for HV
hallux pf, abduction, increased M/L sway
less strength in abductor hallucis, FHB
Greater Abductor Hallus EMG activity during
short foot > toe curl
single leg standing > sitting
toe spread out > short foot
Activation of plantar intrinsic foot muscles increased as
task difficulty increased
Enhancing Recruitment for abductor hallucis
highest force production occurs when 1st MTP joint is positioned between 10-15°of dorsiflexion
Enhancing recruitment in intrinsics/extrinsics
ABDH, FHB, FDB more active during 1st MTP flexion without IP Flexion
FHL and FDL are greater with IP flexion
toe flexion is important for training of intrinsic muscles
Short foot exercises is effective in reducing
foot pronation, foot pain, disability in subjects with pes planus
Results of barefoot weight bearing study
significant increase in CSA of abductor hallucis
significant increase in force during paper grip test
significant improvement in repetition and height
improved strength, balance, fatigue, foot awareness, less pain. increased compliance
Interventions in weightbearing with bare feet
weight bear without shoes
foot exercises bilaterally
short foot
trunk rotation with short foot
post tib
TSO
Pre/Post Intervention Testing for WB in barefeet
plantar pressure in different functional mobility
paper grip test
heel rise
foot muscle structure
Minimal shoe
no motion control
no cushioning
zero drop
no arch support
no midsole
no flares
Minimal shoes vs Foot exercise
minimalist shoe walking is as effective as foot strengthening exercises in increasing foot muscle size and strength
either intervention provides sufficient stimulus to increase muscle strength significantly
Conventional shoes vs Minimal Shoes
wearing minimal shoes for six months, even for non-intensive activities, may increase toe-flexion strength
Minimalist shoes impact on plantar intrinsic foot muscle size and strength
wearing minimalist shoes resulted in increases in IFM size and strength
helpful because it is convenient and there isn’t a time burden
Summary of foot exercise interventions
- short foot, toe spread both benefit HV, HR, PTTD
- Activity and force production of plantar intrinsic muscles is enhanced in standing versus sitting, more so in SLS
- arch and balance mechanisms will benefit from interventions
- barefoot or wearing minimalist shoes increase foot muscle strength
Knee OA and minimal footwear
increases knee function, decreased pain, increased distance during 6 MWT, decreased knee edema
Falls and minimal shoes
improves stability and mobility
movement of center of pressure
improves TUG and STAR tests
Transitioning to Minimal Footwear
- Remove orthotics one hour/day and increase each day. add in orthotic towards end of day with fatigue
- go from high cushion and supportive shoe to low cushion and less support
- Shorter walks in minimal shoes, progress to long walks
- Try walking barefoot
Women face ageism
make clothing choices to conceal or diminish physical markers that would identify them as old
not being able to wear desired footwear and clothing altered women’s body image, with negative impacts on psychological well-being
HV and HR significantly impact confidence, QOL, emotional status, social engagement
Patient’s footwear
more than 70% was defined as being poor
only 5% pts wore their therapeutic footwear
majority selected shoes for fit and comfort
Findings/Conclusions for Foot problems and footwear
- shoes narrower than foot are associated with corns, HV, foot pain
- Women wear shoes that are shorter, narrow, smaller vs men
- Short shoes are associated with lesser toe deformity
- Heel elevation > 25 mm was associated with HV and plantar calluses
How to evaluate fit of shoe
- Length = 10 to 20 mm from longest toe to front of shoes
- Width = grasping of upper over metatarsal, should bunch
- Depth = toes/joints move freely, examine for pressure on toes and nails
- Motion control
Motion of control of foot
fixation of upper to the foot
heel counter stiffness
longitudinal sole rigidity
HV and Orthoses
low level of effectiveness
does improve pain when HV angle improves
HR and Orthoses
morton’s extension if footplate doesn’t work
47% of cases were treated with orthoses
Shoe mods for HR
low heels
stiff sole
rocker bottoms
metatarsal bars
increase in heigh of toe box
Goal of manual therapy interventions
address arthrokinematic impairments that relate to force production
