Biomechanical optimization can play an essential role in remedying varying levels of limited motion at the first MPJ. Accordingly, our panelists share their thoughts and experience on best practices, interventions they try to avoid and adjunctive therapies to improve the success of their orthotic treatment plans.
Q: What features or materials in a custom orthotic do you find most useful for patients with hallux limitus/rigidus?
Karen Langone, DPM, DABPM, FACPM, FAAPSM says her primary goal in the management of hallux limitus and rigidus is to optimize joint motion. To that end, she favors a reverse Morton’s extension and a deeper heel seat to accommodate a medial skive.
Emphasizing the role of range of motion, Richard Blake, DPM, MS, FAAPSM stresses that one must decide if the first MPJ limitation is functional or structural in nature. If it is a functional limitation, he says orthotic devices that reduce pronation and offload the great toe joint with dancer’s padding (reverse Morton’s extensions) are indicated. When it is structural limitation, Dr. Blake does not try to give the first MPJ more motion. Instead, his goal is to achieve a balance between restricting the joint and avoiding uncomfortable overcrowding of the toe with the device or modifications.
“The desired restriction you get from Morton’s extensions sometimes has to come from rocker shoes, like Hoka One One, spica taping or just stiff shoes,” says Dr. Blake.
In general, Dr. Blake finds that functional hallux limitus needs a higher-arch device and hallux rigidus benefits from a lower arch.
“(Patients with) hallux rigidus may be better off with no orthotic device at all or a full-length stiff orthotic device,” adds Dr. Blake.
Brian Fullem, DPM, FAAPSM typically chooses a Morton’s extension made of cork for structural hallux limitus but shares that occasionally in the past, he has used a more rigid extension of the polyethylene shell. Like the previous panelists, Dr. Fullem uses a reverse Morton’s extension to the sulcus as his first-line accommodation to address functional limitations.
In regard to specific materials, Lisa Schoene, DPM, ATC, FACFAS, FAAPSM shares that she traditionally uses a semi-flexible polypropylene for most active patients. She usually employs a 1/8-inch thick version of this material or possibly 3/16-inch if the patient is over 200 pounds. Alternately, Dr. Schoene may utilize an arch fill with crepe or cork rather than using 3/16-inch polypropylene if the patient requires some flexibility.
“I feel very strongly that we have to correct the subtalar joint and the midtarsal joint to align the foot properly in order to allow the first ray to plantarflex via the appropriate pull of the peroneus longus,” says Dr. Schoene. “If the foot functions in a pronated fashion, allowing collapse of the midtarsal joints, the peroneus longus, as it travels under the foot, will lose the effective plantarflexory pull to drop the first ray down. Thus the hallux can not properly dorsiflex at that first MPJ.”
Dr. Schoene prefers a first ray “shell” cutout all the way to the cuneiform in order to allow the first metatarsal to plantarflex against the topcover of the device.
“Using the cutout at the distal corner of the shell does not fully allow the first metatarsal to plantarflex during propulsion,” explains Dr. Schoene. “I might use that option for a sesamoid issue.”
Q: Are there any features or materials that you steer away from?
“Since my goal is to optimize motion, I never use a Morton’s extension,” says Dr. Langone. “Joint motion is essential and eliminating all motion in a joint will cause compensation and overload of the next available joint, which has the same movement planes.”
Dr. Schoene agrees. She says she may occasionally use a wedge to raise the hallux and help to plantarflex the first metatarsal. Dr. Schoene also avoids accommodative soft orthotics, such as those made from foams, noting that they do not go far enough to achieve proper foot alignment.
“From a 30 year anecdotal perspective, with the deep tissue treatments, and the addition of the first ray cut out in the orthotic, patients have very good lasting results,” she relates. “I start with this approach even in hallux rigidus cases, and I discuss with patients that we can always change the device if they continue to have pain. There is no reason to not try getting the joint moving, and I am happy to report this combination, along with toe strengthening exercises and proper shoes works very well.”
In general, Dr. Blake feels that first ray cutouts destabilize the medial column so this option is low on his personal list of modalities for hallux limitus/rigidus. He also tries to stay away from anterior orthotic posts (especially those with a varus bias) since they can block first ray plantarflexion. Lastly, Dr. Blake tries to avoid orthotic devices that are not full-length for these patients.
“Those devices that stop behind the first metatarsal head increase motion there but decrease motion at the metatarsal shaft and midfoot,” elaborates Dr. Blake. “So the painful area becomes the most stressed area, due to the transition between immobility and mobility or from non-motion to motion.”
Maintaining that every patient is different, Dr. Fullem says features such as a first ray cutout can work well for some and not for others.
“I feel it is worth trying different options if your first or second choice does not alleviate the patient’s symptoms,” offers Dr. Fullem. “However, I have gotten away from using more rigid materials for the shell of the device.”
Q: How might you incorporate features specific to hallux limitus into a non-sport custom orthotic?
Dr. Fullem says he aims to treat all of his patients as athletes and will recommend similar devices for athletes and non-athletes with hallux limitus.
Noting that many non-sport or dress devices end just behind the metatarsal heads, Dr. Blake says he might add top covers, extensions or sealants to stiffen the junction between the plastic and the forefoot.
“I traditionally make an orthotic based on the mechanical condition, alignment of the foot and how it is impacts the patient’s function,” says Dr. Schoene. “Weight, activity and occupation all play a role in my decisions of top covers and other corrections. I generally use similar device materials as I do for my athletic population.”
Regardless of device style, Dr. Schoene strives to correct the foot as perfectly as possible. Noting there will always be patients who cannot tolerate full correction, she credits tenacity and in-depth patient education as allowing her to make tweaks while patients break in the devices.
In these instances, Dr. Langone says she generally uses a semi-flexible device to support the natural joint movement in the foot while providing a more optimal functional pattern and alignment. She notes that a unilateral complaint of first MPJ joint limitation usually involves a functional or anatomical limb length discrepancy so she is careful to address this component in her device choice as well.
“The cast/impression of the feet is the most important element as in all conditions,” adds Dr. Langone. “It is also crucial to dorsiflex the hallux while taking the impression to obtain the best result for the patient.”
Q: Is there any other information you would like to share on the topic?
Improving foot strength is a common goal among each of the panelists regarding adjunctive treatments for hallux limitus and hallux rigidus.
“Besides orthotic therapy, it is important to have patients improve their foot strength, especially the flexor hallucis longus (FHL) tendon, while trying to improve the range of motion of the first MPJ,” adds Dr. Fullem. “Proprioception is also extremely important to the function of the feet. I advise the majority of my patients to take turns balancing on each foot when brushing their teeth.”
“I always give the patient intrinsic foot exercises to perform as well as recommendations for a forefoot flexible shoe, again to work with the foot’s natural movement,” says Dr. Langone.
Dr. Schoene often tells patients that hallux limitus and hallux rigidus are interesting conditions.
“We can see the early signs of the disease while evaluating X-rays,” explains Dr. Schoene. “Patients always have an elevated and/or long first metatarsal. I do not believe I have ever seen a patient (other than from trauma) have this condition without those two parameters. Add a pronated foot structure to the foot that has a long and/or elevated first metatarsal, and you create potential for jamming at the first MPJ and a potential progressing limitus scenario.”
Being mindful about the etiology of hallux limitus/rigidus, Dr. Schoene shares her practice’s simple conservative plan, which she says works well in regard to pain relief and avoiding surgery in these patient populations. The key tenets of her conservative treatment plan are as follows:
• foot exercises for all intrinsic and extrinsic muscles and up the kinetic chain;
• deep tissue massage to increase range of motion at the first MPJ, with joint mobilizations, Graston-like tissue work, dorsally and plantarly and some mobilizations along the first ray as well. The session will also have some work along any/all extrinsic musculature that may have trigger points or restrictions as well. Dr. Schoene notes that she sees excellent results sometimes in just two or three one-half hour sessions. Her protocol is a total of five to seven sessions on a weekly or every other week schedule;
• custom orthotics with her previously mentioned preferred features;
• weekly or every other weekly injection therapy utilizing Zeel® (MediNatura); and
• shoe considerations including a rocker-style athletic outsole (sport permitting, not suggested for “lateral” sport athletes), or a bit stiffer outsole especially for women’s shoes.
Dr. Schoene will also suggest a dress pair of orthotics for females keep the foot functioning properly on a daily basis, and eliminate undue stresses to the first MPJ.
Dr. Blake says navigating the various treatment options for hallux limitus and rigidus is a game of pain relief and function.
“At times, we want to limit the motion due to pain and at times, we want to allow the foot to move freely,” explains Dr. Blake. “Sometimes, we make an orthotic device that limits pain but limits normal motion and due to loss to follow up, the patient is still wearing that same orthotic years later. The initial orthotic device, designed to help with a painful joint, supinated the foot too much or it blocks first ray plantarflexion, and needs changing six months later.
“If you make orthotic devices to limit motion, explain to the patient if this is a temporary or permanent measure. The more the patient knows something about the biomechanics involved, the better.”
Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a Past President of the American Academy of Podiatric Sports Medicine.
Dr. Fullem is a Fellow of the American Academy of Podiatric Sports Medicine, and is in private practice in Clearwater, Fla.
Dr. Schoene is a sports medicine specialist and certified athletic trainer who practices in Chicago. She is a Fellow of the American College of Foot and Ankle Surgeons, the American Academy of Podiatric Sports Medicine and the American College of Podiatric Medicine.
Dr. Langone is a Diplomate of the American Board of Podiatric Medicine, a Fellow of the American College of Podiatric Medicine and President of the American Association for Women Podiatrists. She is a Fellow and Past President of the American Academy of Podiatric Sports Medicine and a Trustee of the New York State Podiatric Medical Association. She is in private practice in Southampton, N.Y.