Hallux Valgus and Plantar Plate Injuries
What is the pathogenesis of hallux valgus?
Hallux valgus is a result of disruption of the alignment of the great toe from: 1) Failure of the first MTP joint, medial sesamoid, and medial collateral ligament alignment 2) There is a subsequent medial drift of the metatarsal head and a slipping of the sesamoid apparatus 3) This causes the proximal phalanx of the hallux to move into a valgus position 4) The metatarsal head elevates during medial motion, transferring the plantar pressure laterally to the other rays to be greater than the 10% they are supposed to have (increasing risks for plantar plate injuries and stress fractures also)
What is plantar plate injury characterized by?
Plantar plate injury is commonly characterized by: a) Dorsal subluxation of the proximal phalanx in terminal stance, usually of the 2nd digit b) Dorsal displacement of the interossei relative to the MTP joint, causing an inability to plantarflex the MTP joint c) Medial deviation of the digit
What does post-surgical rehab of hallux valgus involve?
1) Post-operative protection (weightbearing precautions) 2) PROM/mobilization of the 1st MTP joint 3) WB progression to FWB 4) Digit strengthening 5) Normal footwear
What is the plantar plate? What are its attachments?
A fibrocartilaginous structure that lies directly plantar to the metatarsal heads Proximal attachment: a) Deep slips of the plantar fascia acting as a distal extension Distal attachment: a) Base of the proximal phalanx
What is the clinical presentation of hallux valgus?
Clinical presentation: a) Cosmetic deformity of the great toe b) Pain over the medial eminence c) Pain with joint motion of the 1st MTP d) Pain at the plantar aspect of the 2nd MTPJ with weightbearing (because of reduced load from the 1st MTP joint) e) Pain exacerbated with certain footwear f) Hypomobility of the 1st MTP joint that may or not have crepitus g) May or may not have hypermobility of the 1st TMT h) May or may not have MTP joint instability (plantar plate injury)
What is the clinical presentation of a plantar plate injury?
Clinical presentation: a) Pain in the ball of the foot with ambulation b) Plantar edema c) Digit deformity (where the digit is gapped/medially deviated and hyperextended/raised) d) Sagittal plane instability e) Interdigital neuritis f) Maximal tenderness at the insertion of the plantar plate into the base of the proximal phalanx g) (+) Dorsal drawer test h) (+) Footstool edge test (where the digits should relax in PF over the edge of a stool as opposed to hyperextension) i) (+) Paper pull-out test
What does conservative treatment of hallux valgus involve?
Conservative treatment of hallux valgus involves: a) Footwear education b) Activity modification c) Address length, strength, and joint mobility impairments of the LE
What are extrinsic factors that can commonly contribute to the development of hallux valgus?
Extrinsic factors include: a) Footwear (high heels and narrow toe box) b) Excessive weightbearing
True or False: Hallux valgus develops as a progression of a series of steps that slowly build on one another to cause this deformity.
FALSE Hallux valgus develops not as a series of steps, but because of many factors all happening at the same time
What are weightbearing precautions associated with osteotomy vs. joint replacement for hallux valgus? When can they be progressed to FWB?
For an osteotomy procedure = limited WB that can be progressed to initiate FWB at 2-3 weeks For a joint replacement procedure = NWB that can be progressed to initiate FWB at 2-3 months
Post-surgical rehabilitation from bunion surgery usually takes how long to recover?
For osteotomy = ~3-6 months For joint replacement = ~12 months
What is turf toe? How is it treated?
Forced hyperextension/sprain of the great toe that is strictly traumatic in nature Usually treated with rigid taping to control hyperextension
What are indications for surgical intervention of hallux valgus?
If a patient experiences: a) Very severe, debilitating pain b) Severe structural abnormalities c) Increased DMAA
What is the function of the plantar plate?
It provides dynamic and static stabilization/protection of the metatarsophalangeal joints through its attachments to the proximal phalanx and plantar fascia, keeping the toes in place as the foot is loaded
What is the prognosis associated with a lapiplasty of the hallux?
Lapiplasty is a FUSION of the 1st ray that is touted as the "holy grail" of moderate to severe bunion surgery This has POOR patient-reported outcomes (severe pain, swelling, nerve involvement)
What is hallux valgus? ("Bunion")
Lateral deviation of the great toe at the metatarsophalangeal joint It is diagnosed when the metatarsal angle is GREATER than 15 degrees
What mechanism of injury is most associated with plantar plate injuries?
Plantar plate injuries commonly occur due to: a) Barefoot walking on hard surfaces b) High-heeled shoes c) High impact activities (running, jumping) d) Foot/gait impairments e) Faulty mechanics with repeated load
Assess the considerations for surgical intervention of hallux valgus.
There are 44 types of surgical procedures for hallux valgus Since there are so many options that have been explored, there really is no standard for surgical intervention that is best (We just know that it is best to intervene when the condition is in its early stages and there are no proximal changes)
