Happy Thanksgiving!
Mr. TF is a 52 year old pumpkin farmer with a chief complaint of pain and stiffness in both big toes, the left being worse than the right. The problem is exacerbated when he kneels or crouches, or when bending over to feed his turkeys. He remembers a possible injury to the area on his left foot years ago when his wife dropped a large bowl of stuffing on the left foot. The pain comes and goes over the years, but has gradually progressed overall. The left foot sometimes gets red and swollen, and will throb. It sometimes will “catch” or “click” and the toe will spasm. He has tried different work boots, and takes over the counter pain medication but it doesn't help much. His physician instructed him he might have gout, but his blood uric acid levels were considered within normal range. He states he has to work very hard to maintain his farm, and cannot afford to take any time off to take care of his feet.
The patient is 5’11” and weighs 195 pounds. He is on medication for hypertension, which is under control and denies any other medical issues. He does suffer from periodic low back pain, for which he sees a chiropractor. He has no allergies to food or medication, denies smoking, drinks 1-2 beers, 4-5 times per week, and denies recreational drug use.
Lower extremity physical examination findings include normal pedal pulses in both feet, with capillary filling time less than three seconds in all digits. Hair growth is normal, skin tone and temperature is normal. Deep tendon reflexes are equivocal in both Achillies Tendons and â…–+ in both Patellar Tendons. Sharp/dull discrimination is present bilaterally and clonus is absent. Muscle strength is WNL in all groups bilaterally. Range of motion is within normal limits in both knees, ankles, subtalar and midtarsal joints. Examination of the 1st metatarsal phalangeal joints reveal 10 degrees of dorsiflexion on the left, 30 degrees on the right, 10 degrees of plantarflexion bilaterally. There is crepitus in the left 1st MTPJ, which is dorsally enlarged, with some localized swelling, redness and warmth. The lesser digits are all plantigrade. There is callus formation on the medial plantar aspect of both great toes, as well as a crescent shaped callus under the second metatarsal head, left greater than right. The toenails on both great toes are dystrophic and thickened with subungual keratotic debris noted.
Gait analysis reveals symmetry of head position, shoulder height and arm swing. Stride length is normal, hip drop is absent. Mild genu varum is present. Heel contact is mildly inverted bilateral, medial arch arch in slightly lowered left greater than right, abductory twist during heel rise is noted left greater than right and lack of propulsion noted on the left. There is a 2 degree everted resting Calcaneal stance position bilaterally, a 2 degree inverted neutral Calcaneal stance position bilaterally. Forefoot to rearfoot position is 4 degrees of varus on the left and 2 degrees of varus on the right. The first ray is hypermobile bilaterally.
Weight bearing x-rays of both feet were performed. Significant findings include posterior spurring of the Calcaneus, neutral subtalar position, joint space narrowing of the Talar Navicular joints. The first metatarsal is relatively short compared with the second metatarsal and elevated relative to the Hallux on the lateral view. The left 1st MTPJ shows severe joint space narrowing, marginal spurring, sub chondral sclerosis and cyst formation. Osteophyte formation is present dorsally. The right 1st MTPJ has moderate joint space narrowing with mild subchondral sclerosis, absent spurring, cystic changes or osteophyte formation.
Discussion
The diagnosis is Hallux Rigidus of the left foot, Hallux Limitus of the right foot, although gout cannot be totally ruled out at this time. The patient has declined surgical intervention and would prefer symptomatic conservative treatment as well as foot supports. KevinRoot Medical has two models of orthotic devices which may be applicable for this patient.
Which features a Morton’s extension designed to restrict and protect motion of the 1st MTPJ.
Which features a dynamic wedge, which includes a reverse Morton’s extension and dorsal wedge to encourage dorsiflexion of the great toe.
In addition, a separate carbon foot plate is available for enhanced rigidity of the shoe in the forefoot to further restrict the range of motion of the 1st MTPJ.
The clinical decision making regarding pathology of the 1st MTPJ with orthotic therapy, not only in cases of arthritic changes, but with deformity such as hallux abductovalgus, as well as cases where there is both degeneration and deformity can be challenging to even the most seasoned practitioner.
