Skanning

Här syns två 3D-skanningar av fotsulan. Den vänstra bilden visar fotsulans form före strechingen och den högra bilden efter 2 minuters stretching.

Man ser på bilderna att den längsta tån före stretchingen är stortån. Efter stretchingen förändras detta till att den andra tån är längre. Detta förklaras med att hålfoten höjs och stortån följer med och ser kortare ut.

Läs mer bakomliggande studier

Sitta på huk

Bilderna till vänster och höger visar en person som har behandlats 2 x 6 minuter på båda benen och anklarna. Så som bilderna visar kan personen sitta djupare ner på huk efter behandlingarna.

Se fler exempel

Filmerna nedan visar Funktionell Hallux Limitus för och efter behandling, där normal rörlighet i stortåleden har återfåtts.

Ovan är filmer på Funktionell Hallux Limitus före och efter behandling, man ser hur stortåns rörelseomfång har återfåtts. Denna förbättring av rörelsen sker efter alla behandlingar utan undantag!

Testet ovan kan ni låta någon göra på er för att undersöka om ni har Funktionell Hallux Limitus.

Ha knäet rakt och böj upp foten till minst 90 graders vinkel och tryck sedan på stortån, denna ska komma lika långt som utan tryck under fotsulan. Då är det normalt, annars har ni ett tillstånd som bör behandlas och som kommer att ge er besvär i framtiden.

Observera att ni inte skall tvinga stortåleden att komma upp i rörelsen!
Om ni med tvång stressar leden är det risk att ni skadar fotens funktion där stortån ska lyfta fotvalvet. Felet att stortån inte kommer upp sitter INTE i stortåleden!

Den övre filmen till höger visar rörligheten i stortån hos en halux valgus opererad kvinna.
Hon hade besvär i samband med löpning med att tån domnade bort. Vi behandlade stelheten i stortån så att hon kan ta ut steget över stortån normalt utan att leden komprimeras.

Behandlingen gjordes med en Pronatosbehandling med påverkan på fotled och strukturerna på underbenets baksida, utan att behandla själva stortåleden.

Med behandlingen påverkar vi själva uppkomsten av Hallux Valgus, Hallux Limitus och Hallux Rigidus.
Om detta fel fortgår under en tid tvingas man att gå på utsidan av foten som överbelastas, detta leder till besvär under framfoten som, Mortons neurom och andra överbelastningsskador.

Detta stressar även utsidan av fotleden där vadbenet fäster, denna förskjuts uppåt och stressar den övre leden på utsidan av knäet. Eftersom denna ledkapsel kommunicerar med knäledens ledkapsel kan denna irritation ge en svullnad i knäleden. Detta är ett svår diagnosticerat tillstånd som ofta missas med diffusa besvär i knäleden.

Inskränkt rörlighet i stortåleden ger även besvär med höftleden eftersom man måste kompensera stelheten i stortåleden, varje steg ger en stress i rotation eftersom man måste kompensera att man inte kan ta steget normalt över stortån. Antingen vrider man foten i den sekvens som man har den högsta belastningen i höftleden, eller så kortar man av steget med ett hårdare frånskjut med framfoten, vilket stressar höftleden för varje steg man tar.

Facebook  Se vad våra patienter recenserar om Pronatosbehandlingen!

 

Hålfotsinlägg stör fotens funktion

Den viktigaste funktionen i foten är att stortån kan extendera/komma upp ifrån skjutsfasen. Denna funktion lyfter upp hålfoten och ger foten stabilitet. Det enda som lyfter fotvalvet är just denna funktion. Detta är även det vanligaste felet som patienterna kommer med som har ett samband med deras besvär.

Ovan är en film på en patient som har behandlats för just detta besvär och vi testar hur hans gamla hålfotsinlägg påverkade hans fot.

Vi kan se att trycket som inlägget gör på hålfoten stoppar tåns möjlighet att  fungera normalt. Istället för att stödja foten tar den bort fotens egna möjlighet att bli stabil.

Patientfall: Kvinna med smärtor lateralt på höger fot, (Mortons neurom) smärta vid kompression mellan Met 3-4 och 4-5. Vid test visar det sig att patienten har Funktionell Hallux Limitus, med svaghet i Tibilalis posterior och anterior. Patienten analyseras med Win-Pod från Meidicapteurs, där ser man ett förhöjt tryck under gång på lateral sidan av foten samt ökat ryck på Hallux distala falang. Gaitline devierar från mittlinjen lateralt vid framfoten.
Efter behandling med Pronatos metoden (6 minuter) ser man hur Gaitline är korrigerad med mindre tryck lateralt och mindre tryck under den distala falangen på Hallux.
Funktionell Hallux Limitus är korrigerad och fungerar normalt.
Veckan efter vid återbesök är patenten smärtfri vid kompression mellan Met 3-4 och 4-5, deviationen under foten är korrigerad, patienten har normal styrka på Tibialis anterior men en liten kvarliggande svaghet i Tibialis posterior, som förbättras efter åtföljande Pronatos behandlingen igen.

3 veckor efter sista behandlingen är patienten fortfarande smärtfri trots mycket hög träningsbelastning.

Mortons neurom före efter behandling plantar Mortons neurom före efter behandling

Videon visar ett löpsteg där höger fot pronerar mer än vänster.
Personen hade besvär med kramp i vaderna efter en kort löpsträcka.
Efter en behandling har pronantionen korrigerat sig och personen springer obehindrat utan krampkänningar.

Forskningsrapport

En studie på StretchPower om dess effekt att stretcha vadmuskulaturen, gjord på Hälsoteknikcentrum i Halland vid högskolan i Halmstad.
Pilotstudien syftade till att verifiera den omedelbara effekten av att stretcha i stretchpower utifrån ett antal fysiska parametrar.

Länk till rapporten

Forskning på Funktionell Hallux Limitus och Equinus/stela vadmuskler och konservativ behandling.

 

Plantar Fasciitis and Its Relationship with Hallux Limitus

Conclusions

Hallux dorsiflexion was reduced in patients with PF who participated in the present study. This characteristic may have favored development of the pathologic abnormality by creating additional tension in the plantar fascia. The pronated foot was the most frequent type in the PF group. It is possible, therefore, that excessive subtalar pronation may be a biomechanical alteration that influences the etiology of PF.

Yolanda Aranda, PhD*, Pedro V. Munuera, DPM*

https://www.researchgate.net/publication/262885679_Plantar_Fasciitis_and_Its_Relationship_with_Hallux_Limitus

http://www.japmaonline.org/doi/abs/10.7547/0003-0538-104.3.263?code=pmas-site&journalCode=apms

Flexor Hallucis Longus Dysfunction

Lawrence M. Oloff, DPM, and S. David Schulhofer, DPM1

Conclusion

Anatomic pulley mechanisms exist to enhance tendonfunction, and the increased incidence of tendon injuryat these sites is well known. As a result of extrinsicand/or intrinsic repair processes, stenosing tenosynovitismay develop and normal range of motion may becomepainful and/or restricted. Flexor hallucis longus stenosingtenosynovitis is a well-recognized disorder among classical ballet dancers and is occasionally seen in running athletes. There are no reports concerning nonathletes and the disorder likely exists as a diagnosis of exclusion among the general population.

The prevalence of FHL stenosing tenosynovitis may be higher than reported. A relatively large number of patients were encountered during a short time frame; patients were primarily nonathletic, male, and two times the average reported age. In addition, overlapping signs and symptoms of FHL tendinitis, plantar fasciitis, and tarsal tunnel syndrome were present in many of the patients. Without a high index of suspicion, misdiagnosis may be encouraged, contributing to chronic FHL tendon injury that may decrease the opportunity for a nonoperative recovery.

The presence of plantar fasciitis that fails to respond to standard nonoperative protocols should be evaluated for FHL tendinitis. Many patients presented with an apparently painful medial plantar fascial band that was recalcitrant to nonoperative measures, yet obtained 100% pain relief during the tenogram anesthetic phase, and permanent relief after FHL tenolysis. Flexor hallucis longus stenosing tenosynovitis may be more prevalent than previously suspected and should be a diagnosis of inclusion among all patient populations with posterior ankle pain, medial arch pain, and/or tarsal tunnel symptoms. The term flexor hallucis longus dysfunction has been used to describe patients presenting with these unique features. Magnetic resonance imaging and tenography are valuable in establishing the diagnosis. FHL tenolysis has proven to be a relatively safe, successful, and reproducible procedure in recalcitrant cases.

https://www.ncbi.nlm.nih.gov/pubmed/9571456

Plantar pressure distribution in normal, hallux valgus and hallux limitus feet

A. Bryant,* P. Tinley,† K. Singer†

CONCLUSIONS

Selected dynamic plantar pressure measurements of 30 control, 30 hallux valgus and 30 hallux limitus subjects, were analysed for significant differences. Hallux valgus feet demonstrated significant medial localization of peak and mean pressures, suggesting foot pronation is an important factor in the development of this condition. While hallux limitus feet showed a significant locus in mean pressure under the hallux, third and fourth metatarsal heads and lesser toes, indicating a degree of lateral bias forefoot load. From this work, it would appear that the functional pathomechanics of hallux valgus and hallux limitus feet are considerably different.

These findings may be of value in assessing and monitoring patients with forefoot pathology or screening individuals at risk of developing hallux valgus or limitus so that appropriate advice or interventative treatment may be considered.

A cross-reference of patients with posteromedial ankle pain, medial arch pain, and/or a positive Tinel’s sign

Functional Hallux Limitus and Lesser-Metatarsal Overload

James G. Clough, DPM*

Conclusion

The function of the first metatarsophalangeal joint may be most critical for normal foot function and for prevention of a host of foot pathologies. It has been shown that most normal feet demonstrate functional hallux limitus. A relatively simple treatment for this condition has been proposed, and it is hoped that this treatment will become another tool that clinicians will have at their disposal to treat functional hallux limitus and lesser-metatarsal overload and the resulting sequelae.

http://www.japmaonline.org/doi/abs/10.7547/0950593?journalCode=apms

Functional Hallux Limitus an unrecognized cause of Hallux Valgus or Hallux Rigidus. Review.

Authors:

* **Jacques Vallotton MD, FMH Orthopaedic Surgery, Sports Medicine. *Santiago Echeverri MD, MBA. FMH Orthopaedic Surgery.

*Vinciane Dobbelaere-Nicolas, Physiotherapist, Podologist.

Conclusion

The Functional Hallucis Limitus is a frequently misdiagnosed clinical entity and its effect on the evolution of Hallux Rigidus and Hallux Valgus has been underestimated. Its diagnosis is clinical and requires a high degree of suspicion. It is caused in the large majority of cases by a tenodesis effect on the Flexor Hallucis Longus tendon and can be demonstrated by the “Flexor Hallucis Longus Stretch Test” that is diagnostic. The tenodesis effect induces a sagittal plane blockade inducing a time lag during gait requiring a series of compensatory mechanisms that are not limited to the foot.

Functional Hallux Limitus deserves an early diagnosis and treatment to prevent the evolution of invalidating degenerative deformities on the MTP1: Hallux Rigidus and Hallux Valgus. Especially in the light of simple, effective diagnostic tests and low risk therapeutic options ranging from physiotherapy to endoscopic release of the Flexor Hallucis Longus tendon. Clinicians should look systematically for the presence of Functional Hallucis Limitus.

https://www.researchgate.net/profile/Jacques_Vallotton/publication/228811942_Functional_Hallux_Limitus_an_unrecognized_cause_of_Hallux_Valgus_or_Hallux_Rigidus_Review/links/563149c308ae13bc6c357933.pdf

Functional Hallux Rigidus and the Achilles-Calcaneus-Plantar System

Ernesto Maceira, MD*, Manuel Monteagudo, MD

SUMMARY

Functional hallux rigidus is a clinical condition in which the mobility of the first MP joint is normal under non-weight-bearing conditions, but its dorsiflexion is blocked when the first metatarsal is made to support weight. It may be present in asymptomatic subjects or become incapacitating. Throughout its evolution, it goes from being a phenomenon that must be looked for to provide a diagnosis to a medical condition of florid arthrosis of the first MP joint. The author thinks that it is at the origin of mechanical hallux rigidus and is considered different phases of the same condition.

In mechanical terms, functional hallux rigidus implies a pattern of interfacial contact through rolling, while in a normal joint contact by gliding is established. The windlass mechanism is essential to maintain the plantar vault and is based on the correct functioning of an arch formed by several bony elements that work through compression and foot braces, which work through tension, among which the best prepared for its moment arm is the plantar aponeurosis. This forms a functional unit with the Achilles-calcaneal-plantar system, thanks to the enthesis/enthetic organ of the heel, meaning excessive traction of the triceps will be transmitted directly or indirectly to the fascia. Pronation of the foot and blockage of heel dorsiflexion may increase the tension in the aponeurosis. Both the elevation of the head of first metatarsal and the  increase in tension in the aponeurosis may alter the joint dynamics in the first MP joint, producing contact by rolling instead of physiologic interfacial contact through gliding.

Furthermore, each one of these alterations may give rise to the other. Equinus due to the shortening of the elastic component of the calf muscles is a frequent finding among the general population, probably as a vestige of what our foot was millions of years ago. Limitation of the dorsiflexion in the ankle or the MP joint blocks the forward movement of the tibia during the stance phase on the sagittal plane, which is compensated through diverse mechanisms that entail abnormal movements on other planes and in other body segments. The compensatory mechanisms are usually tolerated well, but they may also produce pain or impairment, thus becoming medical conditions.

Orthopedic and surgical measures are at our disposition to treat the blockage of movement on the sagittal plane. Among the latter, the lowering and stabilizing of the head of first metatarsal and the lengthening of all or part of the triceps are favorable mechanical procedures to resolve the blockage.

Patients with functional hallux rigidus should only be operated on if the pain or disability makes it necessary. Gastrocnemius release is a beneficial procedure in most patients.

https://www.ncbi.nlm.nih.gov/pubmed/25456716

The Non-Surgical Treatment of Equinus.

Equinus deformity has been associated with over 96% of biomechanically-related foot and ankle pathologies.

http://www.podiatrym.com/pdf/2015/6/DeHeer615web.pdf

Hallux Rigidus Nonoperative Treatment and Orthotics

Remesh Kunnasegaran, MBChB (Glasgow), MRCS (Glasgow)Gowreeson Thevendran, MBChB (Bristol), MFSEM (UK), FRCS Ed (Tr & Orth)*

Plantar pressure distribution in normal, hallux valgus and hallux limitus feet

Bryant,* P. Tinley,† K. Singer†

SUMMARY

Although the literature is polarized by studies in support of operative management, there is a reasonable body of evidence to substantiate the role of nonoperative management for hallux rigidus. At present, there is conflicting evidence for the role of manipulation and injection therapy. There is weak evidence to support the role of orthotics and supportive shoes for the treatment of hallux rigidus and this treatment modality may be best suited for lower grades of hallux rigidus and selected groups of patients. There is a paucity of strong evidence to substantiate the role of physical therapy for hallux rigidus. The application of newer experimental modalities, such as extracorporeal shockwave therapy, iontophoresis, and ultrasonography therapy, although increasing in popularity, has yet to be shown to be an evidence-based practice for the treatment of hallux rigidus.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3819471/

The Effect of Sesamoid Mobilization, Flexor Hallucis Strengthening, and Gait Training on Reducing Pain and Restoring Function in Individuals With Hallux Limitus: A Clinical Trial

Jennifer Shamus, PT, PhD, CSCS1, Eric Shamus, PT, PhD, CSCS2, Rita Nacken Gugel, PhD3, Bernard S. Brucker, PhD, ABRP4, Cindy Skaruppa, PhD5

CONCLUSION

For health professionals working with individuals 26 to 43 years of age who have a painful but functional hallux limitus, a comprehensive program of physical therapy (including whirlpool, ultrasound, ice, electrical stimulation, and MPJ mobilizations and exercises) coupled with sesamoid mobilizations, flexor hallucis strengthening, and gait training appears to be more effective than a comprehensive physical therapy program alone. In our study, this treatment, when performed for 12 visits distributed over 4 weeks, resulted in a significant increase in hallucis ROM, strength, and function, and a significant decrease in pain. Given the results of the present study, physical therapists should consider this approach in the management of this condition.

http://www.jospt.org/doi/pdf/10.2519/jospt.2004.34.7.368?code=jospt-site

The Effect of Gastrocnemius Tightness on the Pathogenesis of Juvenile Hallux Valgus: A Preliminary Study

Louis Samuel Barouk, MD. L. S. Barouk – Publications – ResearchGate

SUMMARY

Hallux valgus is the most frequent consequence of gastrocnemius tightness in the foot. This condition is particularly evident in juvenile hallux valgus. There are anatomic and biomechanical links between the gastrocnemius muscles and the hallux: Achilles tendon, calcaneum, plantar aponeurosis, plantar plate, and sesamoids. Thus gastrocnemius tightness exerts a deforming force on the hallux, which is well established for hallux limitus (windlass mechanism) but is not widely understood for hallux valgus. It is hoped that the present study addresses this. Isolated gastrocnemius tightness, through tension in the plantar aponeurosis and the oblique direction of its medial part, results in valgus and plantar deforming forces at the 1st MTPJ. This is defined as the oblique windlass mechanism, and causes, or at least is an exacerbating factor in the pathogenesis of, hallux valgus.

Clinical consequences for clinicians are, first, that it is essential to evaluate the gastrocnemius tightness in any case of juvenile hallux valgus, then to consider correcting this tightness each time it is required. This evaluation not only serves to secure the results of the bunionectomy but also to avoid, diminish, or at least to ensure the success of surgery of the lesser rays in cases of metatarsalgia. In addition, it corrects other signs of gastrocnemius tightness: lumbago, cramps or calf tension, difficulty walking in bare feet or flat shoes, and eventually hindfoot problems (ie, Achilles tendinopathy, plantar fasciitis).

https://www.researchgate.net/profile/L_Barouk/publications

The Effect of the Gastrocnemius on the Plantar Fascia

Javier Pascual Huerta, PhD

SUMMARY

In this article, a functional relationship has been proposed between both structures that goes beyond a simple anatomic relationship. From the model presented herein, tightness of the gastrocnemius muscle produces an increase in Achilles tendon tension during weight-bearing activities and increasing dorsiflexion stiffness of the ankle joint. Increased tension in the Achilles tendon during weight-bearing produces plantarflexion moments at the hind foot and an increase in forefoot plantar pressure with an anterior displacement of center of pressure. The combination of hind foot plantarflexion moments and forefoot dorsiflexion moments tend to collapse the arch, and the plantar fascia increases its passive mechanical longitudinal tension counteracting the arch flattening effect of gastrocnemius tightness. With these ideas in mind, the relationship between the gastrocnemius muscle and the plantar fascia could be considered as a relationship derived from the mechanical behavior of the foot in weight-bearing conditions instead of direct transmission of tension through the calcaneal trabecular system. Although the model presented has some limitations, such as the effect of intrinsic foot and deep posterior calf muscle contraction, it can serve for a better understanding of the effect of gastrocnemius tightness in specific foot disorders.

These ideas can also help to explain clinical findings of patients with gastrocnemius tightness and open new possibilities of treatment for specific foot problems, such as plantar fasciitis, metatarsalgia, midfoot dorsal pain, and forefoot ulcerations of neuropathic patients.

https://www.ncbi.nlm.nih.gov/pubmed/25456717

Gastrocnemius Shortening and Heel Pain

Matthew C. Solan, FRCS (Tr&Orth)a,b,c,d,*, Andrew Carne, FRCRaMark S. Davies, FRCS (Tr&Orth)d

SUMMARY

Contracture of the gastrocnemius produces subtle alterations to gait and posture.

There is a resultant increase in the strain in the Achilles tendon and also the plantar fascia. Patients with recalcitrant heel pain commonly have isolated gastrocnemius contracture that can be shown using the Silfverskiold test.

Eccentric calf stretching is one of the few interventions that has been proved to be useful in the management of plantar fasciopathy and Achilles tendinopathy. As part of the investigation and management of recalcitrant heel pain any contracture of the gastrocnemius should be identified using the Silfverskio¨ ld’s method. If formal eccentric stretching of the gastrocnemius does not result in improvement in the symptoms and the contracture persists, then surgical gastrocnemius lengthening should be considered. PMGR is the preferred technique for most patients because the recovery is rapid, the procedure has a very low morbidity, and it can be performed under local anesthesia with sedation (avoiding the need for full GA in the prone position). If there is extreme contracture then the surgeon must decide whether to release the lateral head of the gastrocnemius proximally at the same time or perform a Strayer procedure instead.

Local treatments for either the Achilles tendon or the plantar fascia should be deferred until any calf contracture has been corrected, which is often by stretching under physiotherapy supervision, but orthopedic surgeons should be aware of the occasional need for gastrocnemius lengthening. The PMGR technique, developed by L.S. Barouk and P. Barouk in France, is an excellent method with extremely good functional results, a low risk of complications, no need for postoperative immobilization, and once mastered is performed under local anesthetic. In time this will become the technique of choice for gastrocnemius lengthening. In our practice the Strayer is reserved for extreme contracture only and in 95% of cases we prefer the Barouk method.

https://www.ncbi.nlm.nih.gov/pubmed/25456718

Functional Hallux Limitus A Review

Beverley Durrant, MSc, BSc(Hons) Pod*, Nachiappan Chockalingam, PhD†

Conclusions

In reviewing the literature on functional hallux limitus and the reported effects that it may have on gait, it becomes clear that the plethora of available information provides the reader with a vast array of both scientific evidence and theoretical debate. Many of the clinical tests carried out in practice are based on historical approaches and anecdotal findings. New research and theories based on these methods may run the risk of adding to the already confusing minefield of opinion and theoretical reasoning rather than providing clinicians with sound scientific research on which to base their practice. Nevertheless, the way in which some new theories are being challenged is encouraging and is demonstrative of how evidencebased practice is being embraced. Perhaps the way forward is to continue the debate and encourage clinicians to engage in quantitative research that uses robust, valid, repeatable, and reliable clinical measures that will provide empirical primary research to underpin the theory and provide evidencebased practice for the future. This is particularly important in foot function because it is the only part of the body in contact with the ground during bipedal ambulation. Further research must include the effect that abnormal foot function may have on more proximal structures, and therefore collaborative multidisciplinary research would be useful. The use of motion analysis gives a way forward for researchers to gather accurate kinematic data, and perhaps using this method for data collection may go some way to provide a standardized framework for kinematic analysis of the small joints of the foot that are often difficult to measure.

https://www.researchgate.net/publication/24433088_Functional_Hallux_Limitus

Dorsalflexion i första metatarsofalangealleden och naviculare position hos motionärer med Achilles tendinopati i mittportionen

Gunilla Vogel

Konklusion: Motionärer med unilateral AT har nedsatt dorsalflexion i MTP 1-leden på den affekterade sidan jämfört med friska. Inga sidoskillnader verkar finnas beträffande naviculare position. GM är att föredra framför VE vid klinisk mätning av dorsalflexion i MTP 1-leden, eftersom rörligheten underestimerades vid VE

http://www.diva-portal.org/smash/get/diva2:812031/FULLTEXT04.pdf

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Intresserad? Lär dig mer!

Vi har nu införskaffat avancerad mätutrustning som mäter fotens tryck och rörelse, med denna kan man se förändringar på fotens biomekanik före och efter behandling.

Patientfall: Kvinna med smärtor lateralt på höger fot, (Mortons neurom) smärta vid kompression mellan Met 3-4 och 4-5. Vid test visar det sig att patienten har Funktionell Hallux Limitus, med svaghet i Tibilalis posterior och anterior. Patienten analyseras med Win-Pod från Meidicapteurs, där ser man ett förhöjt tryck under gång på lateral sidan av foten samt ökat ryck på Hallux distala falang. Gaitline devierar från mittlinjen lateralt vid framfoten.
Efter behandling med Pronatos metoden (6 minuter) ser man hur Gaitline är korrigerad med mindre tryck lateralt och mindre tryck under den distala falangen på Hallux. Funktionell Hallux Limitus är korrigerad och fungerar normalt.

Veckan efter vid återbesök är patenten smärtfri vid kompression mellan Met 3-4 och 4-5, deviationen under foten är korrigerad, patienten har normal styrka på Tibialis anterior men en liten kvarliggande svaghet i Tibialis posterior, som förbättras efter åtföljande Pronatos behandlingen.

Mortons neurom före efter behandling plantar        Mortons neurom före efter behandling