Hallux valgus dnbid 2nd version lecture 2012

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Hallux Valgus:

Hallux Valgus Dr. D. N. Bid [PT] Sarvajanik College of Physiotherapy, Surat.

BUNION:

BUNION The term bunion stems from the Latin word bunio , which means “turnip,” સલગમ an image suggestive of an apparent growth or enlargement around the joint. The medical term for this is hallux valgus. Hallux valgus is a common deformity of the forefoot and the most common deformity of the first metatarsophalangeal joint (MTP), often causing pain (Figs. 76-1 and 76-2).

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The pathophysiologic process stems from both the proximal phalanx and the metatarsal. The proximal phalanx deviates laterally on the head of the first meta-tarsal, exacerbated by the pull of the adductor hallucis muscle.

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The lateral capsule becomes contracted, and the medial structures are attenuated. The metatarsal deviates medially, but the underlying sesamoids remain in their relationship to the second metatarsal, thus creating dissociation of the metatarsal-sesamoid complex.

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As these two processes occur together, the pull of the abductor hallucis moves more plantarly and the pull of the extensor tendon moves laterally, causing pronation and further lateral deviation of the great toe, respectively. As the metatarsal head becomes more uncovered, a prominent medial eminence or bunion is apparent. There is a bursa between the metatarsal head and the skin that may become inflamed and painful.

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Depending on the amount of axial rotation of the first metatarsal and pronation of the toe, the first ray becomes dysfunctional, leading to increased weight bearing on the more lateral metatarsal heads and “transfer metatarsalgia,” causing pain under the plantar aspect of the forefoot.

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The etiology of hallux valgus is multifactorial and can be either intrinsic or extrinsic. The intrinsic causes are essentially genetic and are related to hypermobility of the first ray (hallux metatarsal) at its articulation with the medial cuneiform. Ligamentous laxity (e.g., Marfan syndrome, Ehlers- Danlos syndrome) can lead to this deformity as well as to variations in the shape of the metatarsal head (i.e., a rounder head is less stable than a flat one).

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Another contributing factor is metatarsus primus varus, or medial deviation of the first metatarsal, which is thought to be associated with a juvenile bunion. Pes planus and first metatarsal length have also been evaluated for their contribution to hallux valgus, but findings were equivocal.

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The principal extrinsic cause is inappropriate, nonconforming footwear, with abnormal valgus forces creating deformity. This is particularly notable in women who wear high-heeled shoes with narrow toe boxes. The ratio of hallux valgus between women and men has been reported to be 15:1.

SYMPTOMS:

SYMPTOMS The patient may complain only of a painless prominent medial eminence. However, more commonly, there will be pain that is worse when constrictive shoes are worn and relieved by walking barefoot or with open-toed shoes. If there is significant arthritis, patients may have pain throughout range of motion of the MTP joint while walking.

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The bunion may become red and inflamed as the bursa enlarges and overlying skin becomes abraded by the shoe. The patient will have difficulty finding comfortable shoes. As the hallux deviates into increased valgus, it tends to impinge on the medial aspect of the pulp of the second toe, causing pressure and soreness.

PHYSICAL EXAMINATION:

PHYSICAL EXAMINATION There is generally an obvious medial enlargement overlying the metatarsal head, with occasional signs of inflammation (bursitis). The great toe will be laterally deviated, and with progression of deformity, it will be pronated (axially rotated). There may be splaying of the forefoot and callosities visible under the metatarsal heads of the lesser toes.

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Passive extension of the hallux MTP joint will reveal any limitation of range of motion (normally approximately 70 degrees). This may indicate concomitant degenerative joint disease of the MTP joint. Mobility of the hallux at the first metatarsal-medial cuneiform joint is assessed in relation to the second ray. Hammer toes are commonly noted as a consequence of the crowding in the shoe by the great toe.

FUNCTIONAL LIMITATIONS:

FUNCTIONAL LIMITATIONS Limitations are principally in walking long distances and wearing shoes with a narrow toe box or high heels for prolonged periods. As hallux valgus progresses, arthritis may become a component and lead to stiffness and pain with any activity (biking, hiking, walking short distances, or even standing).

DIAGNOSTIC STUDIES:

DIAGNOSTIC STUDIES Weight-bearing plain radiographs will provide most of the necessary information. The anteroposterior view (Fig. 76-3) demonstrates the angle (Fig. 76-4) between the first and second metatarsals ( intermetatarsal angle). The congruency of the first MTP joint can also be assessed for any evidence of arthritis. These all have a bearing on any proposed surgery.

TREATMENT:

TREATMENT Initial NSAIDs and analgesics may be used to alleviate pain. However, key measures include education about footwear, namely, shoes with low heels, well-cushioned soles, extra depth, and broad toe boxes.

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Many orthoses are available of varying efficacy. These include sponge wedges to be placed in the first web space, more formal braces that attempt to pull the hallux into a more neutral position, and custom-molded orthotic appliances to resist foot pronation and to encourage larger shoes.

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Rehabilitation Once the structural deformity has progressed, physical therapy has a limited role. This includes mobilization of the first MTP joint and strengthening of the intrinsic muscles of the foot, which may improve symptoms. Distraction techniques like varus stretching or toe spacers may also be useful.

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Procedures Local anesthetic and steroid injection into the first MTP joint may provide short-term pain relief but is certainly not curative and generally not recommended.

Surgery:

Surgery After conservative management has failed, surgery is a consideration. Over the years, a vast array of different surgical procedures have been described. Furthermore, no single procedure has provided sufficient evidence of being superior to any other. The complication and recurrence rates can be relatively high, and satisfaction of the patient is difficult to achieve.

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A study reported that the desired outcome of surgery for patients is threefold: a painless great toe that “when wearing conventional shoes, gives no problems,” an improvement in the bursitis and appearance of the bunion, and the ability to walk as much as they wish.

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These are not unreasonable goals, but it is very important to counsel patients preoperatively, explaining the complications and that there are no guarantees they will be able to return to wearing high-heeled fashionable footwear. The principal goals of surgery are to relieve pain and to provide a foot capable of wearing a shoe.

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The type of surgery, whether it is a distal soft tissue procedure combined with a proximal metatarsal osteotomy, a distal osteotomy alone, or even an MTP arthrodesis, depends on the presenting anatomic deformity and its complexity.

POTENTIAL DISEASE COMPLICATIONS:

POTENTIAL DISEASE COMPLICATIONS Disease complications include ulceration of the medial eminence, metatarsalgia, callosities, hammer toe deformity, and stress fractures of the lesser toes.

POTENTIAL TREATMENT COMPLICATIONS:

POTENTIAL TREATMENT COMPLICATIONS Analgesics and nonsteroidal anti-inflammatory drugs have well-known side effects that most commonly affect the gastric, hepatic, and renal systems. Treatment can result in recurrent hallux valgus deformity, hallux varus from surgical overcorrection, and hallux extensus (cock-up toe). Procedures in which the first metatarsal is excessively shortened may result in transfer metatarsalgia.

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Osteonecrosis of the first metatarsal head can occur if the blood supply is disrupted signifi cantly . Nonunion can occur with the osteotomies and MTP arthrodesis.

Management / Interventions :

Management / Interventions Non-operative treatment The first treatment option is non operative care: Adjustment to footwear help in eliminating friction at the level of the medial eminence (bunion), e.g., patients should be provided of a shoe with a wider and deeper tip Correct the pes planus with orthosis . A sever pes planus condition can lead to a recurrence of hallux valgus following surgery. Achilles tendon contracture may require stretching or even lengthening This type of treatment can be applied in the early stage when the secondary contractures of the soft tissues and the alterations of the articular surfaces have not become permanent .

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Operative treatment There are several surgical procedures that we can apply depending on the severity of the injury: For mild cases: distal soft tissue procedure Hallux angle < 30 °: Chevron osteotomy Hallux < 25 °: Akin procedure Age > 65 year: Keller arthoplasty Arhrodesis (the most common)

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Post-operative physiotherapy As a result of the gait disturbances (see non-operative treatment), objectives for physical therapy could be: Adjusted footwear with wider and deeper tip Increase extension of MTP joint Relieve weight-bearing stresses ( orthosis ) [6]

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Sesamoid Mobilization :*The physical therapist performs grade III joint mobilizations on the medial and lateral sesamoid of the affected first MPJ. He / she places 1 thumb on the proximal aspect of the sesamoid en applies a force from proximal to distal that causes the sesamoid to reach the end range of motion = distal glides. These are performed with large-amplitude rhythmic oscillations. No greater than 20° of movement of the MPJ is allowed during the technique. [9] Strengthening of the Peroneus Longus [10] Gait Training [9] .

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These objectives should ensure that pain is reduced and function is restored. [9] Physiotherapists should contain an expanded program, including whirlpool, ultrasound , ice, electrical stimulation, MTJ mobilizations and exercises. This is more effective than a physical therapy alone. The combination will result in a increase in ROM MTP joint, strength and function and also a decrease in pain.

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Post -op Rehabiliatation Considerations For all surgical procedures, the patient is allowed to ambulate in a post-operative shoe immedidately after surgery. Patients come out of surgery needing to wear a post-op shoe and compressive dressings for 8 weeks Long term follow up has shown equally positive outcomes after Chevron osteotomy for both patients both younger and older than 50.

stages 1:

stages 1 from adolescents to 25 y/o bunion presents as a slight bump

Stage 2:

Stage 2 from 25 y/o to 55 y/o 1st metatarsal head adducts, hallux abducts ,callosity on medial site of 1st MTP joint Foot continues to pronate

Stage 3:

Stage 3 overlapping of hallux either above or below 2nd digit Hard to find footwear extreme pain, need surgical correction

Diagnostic imaging:

Diagnostic imaging Weight-bearing radiographs Hallux valgus angle ( HVA ) normally < 15-20 ° The 1-2 intermetatarsal angle ( 1-2 IMA ) normally < 9 ° ° °

Orthotic:

Orthotic

Surgical Technique:

Surgical Technique HVA IMA Procedure < 40 ° < 13° to 15° modified McBride or distal chevron osteotomy < 40 ° > 13° to 15° modified McBride and proximal osteotomy >40° > 20° modified McBride and proximal osteotomy or arthrodesis

Surgical Technique:

Surgical Technique

Modified McBride Procedure:

Modified McBride Procedure

Distal Chevron Osteotomy:

Distal Chevron Osteotomy

Distal Chevron Osteotomy:

Distal Chevron Osteotomy

Proximal Metatarsal Osteotomy:

Proximal Metatarsal Osteotomy

Proximal Metatarsal Osteotomy:

Proximal Metatarsal Osteotomy

Thank u…4 being so patient.:

Thank u…4 being so patient.

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