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Sunday, April 5, 2015

Hallux Limitus Discussion: Dancer's Padding or Reverse Morton's Extensions

​Dear Dr. Blake,

     I am a senior podiatry student. I was just reading one of your blog posts (Sesamoid Fractures: Advice when not healing well) and I have a couple of questions I was hoping you could clarify for me.

     My questions actually have to do more with hallux limitus. I have been trying to understand the difference between offloading the 1st MPJ with a dancer's pad for conditions such as sesamoiditis versus using a reverse mortons extension for a hallux limitus. Essentially they seem to be the same pad? But how could one be offloading and relieving pressure while the other one is increasing plantarflexion of the 1st MPJ (and I assume that would be increasing pressure) to decrease the elevatus?
Dr Blake's comment: Dancer's pads and Reverse Morton's Extensions are one and the same. I would rather give credit to the French who in the 1770s while studying their ballet dancers came up with this unique pad for big toe joint pain. It was the time of the French Revolution, but also the time of this unique pad that was not placed over the sore area, but designed to transfer weight. A truly revolutionary idea!! A dancer's pad should transfer weight from the first metatarsal to the second through 5th metatarsals at push off. When this works, normal push off occurs with the first metatarsal being free to plantarflex for an active push off. When there is too much weight on the first metatarsal (say from over pronation of the foot), then functional jamming and pain can occur as the first metatarsal tries to plantarflex at push off but is being restricted. So, at push off you want normal plantarflexion of the first metatarsal, with normal to slightly less than normal plantar pressures. This can help a pain syndrome produced by that jamming force. And, push off is only one third of stance. Dancer's pads do eliminate a lot of pressure on the first metatarsal during the contact and midstance phases. So, all 3 phases of stance have less pressure on the first metatarsal with a dancer's pad, and active push off should be less restricted and therefore more powerful. Now, a structural met primus elevatus is best helped by a Morton's Extension. It brings the ground up to the first metatarsal and allows it to function normally. A functional met primus elevatus, caused by over pronation, is only elevated by the pronation jamming it upward. It needs arch support to decelerate pronation, shifting the weight in midstance to the middle of the foot, with a dancer's pad to free up the jammed big toe joint. Besides Dr Root, Dr Langer first discussed this concept in the 1980s. Drs Wernick, Langer and Dannenberg introduced the kinetic wedge with first ray cut outs to free up the first metatarsal to achieve wonderful push off. The basic concept was that some arch support, and some first ray freedom, would help the first ray push off. This is achieved in various orthotic modifications. I love adequate over pronation correction from the orthotic device, along with some dancer's pad to give extra freedom. Dancer's pads have been crucial in pain syndromes, and less necessary when there is no pain (although always an option to add). 

Also, If someone has a hallux limitus and a plantar plate tear of the second, would you recommend doing a spica taping to the first and the second toe simultaneously? Your instructional video on Youtube for this is excellent. My mom actually has this issue and I have been trying to research different taping methods since she does not want surgery. I bought her a morton's extension innersole but she also doesn't wear sneakers very often as she is a dancer. She is hypermobile so perhaps using a reverse mortons extension may help the joint align. However, I am worried to add pressure to the sesamoids because she also states she has pain there (hence my confusion on padding). I have included a photo of her foot and x-ray just in case my rambling doesn't make sense.
Dr Blake's comment: Even though you are only a student, you are asking great critical questions. The main treatment for a plantar plate tear is a Budin splint or spica tape to the 2nd/3rd toes (typically buddy tape to share the pressure). Look at the Hapad products. Start with an Extra-Small Longitudinal Medial Arch for the Hallux Limitus to shift weight more central. Add a Budin splint for the 2nd/3rd toes (Single loop opened up for both toes). You can trim the Budin splint plantar padding as much as you like, and you can even add an extra small metatarsal pad to the splint. 
Dr Blake's comment: The xrays point to that long first metatarsal that gets jammed at push off. This is typically initially a functional jamming (functional hallux limitus), which can become osteoarthritis (structural limitus or rigidus). Since you can not load the second met head, you have to support the arch to transfer weight from first to central. 

 She also has a strange lump on the medial 2nd digit. She was told by a podiatrist that it was just bursitis but I am not convinced since it is a hard lump- feels almost like an extension of the medial condyle of the prox phalynx...the x-ray just looks like a bit of increased density in the soft tissue. Have you ever seen something like that before?

Dr Blake's comment: With plantar plate tears, the second toe can start to deviate to the the loss of plantar ligament stability. Here you see the second toe proximal phalanx deviating towards the first toe. She may need that fixed surgically some day. And, today definitely needs to live with a Single loop Budin splint with the loop opened up enough to cover both the second and third toes. I sure hope this helps her and good luck with your career. Rich

I am going to have her start doing the joint mobilization that you recommend in your other blog post.

So sorry for the long e-mail. I really appreciate you taking the time to read this. I am looking forward to your response. 

Best Regards,

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.