The purpose of this article is to present a practical, biomechanical approach to managing various common forefoot deformities.
When a patient’s chronic heloma dura becomes markedly symptomatic, periodic palliation may become less appealing to them and another solution may be more appropriate. When the lesion is associated with a contracted lesser digit, it is essential for the practitioner to assess the overall mechanics of this foot. Generally, a painful lesion overlying a contracted 4th and/or 5th digit associated with a compensated or uncompensated forefoot varus deformity will not respond favorably to functional orthotics alone. The orthotic may even aggravate the condition, as the lateral aspect of this foot is placed rigidly against a toe box. Either a digital orthosis or surgical correction will have to be considered in addition.
Conversely, a patient who has a painful heloma dura associated with a flexible type of forefoot valgus will generally respond favorable to orthotics alone. The contracture diminishes as the forefoot is no longer required to grasp for lateral stability. A digital orthosis will assist greatly in diminishing the contracture.
Hallux Abducto Valgus (HAV)
During the course of its progression, a HAV deformity passes though four various stages. During the initial phases, which are characterized by clinical as well as radiographic demonstrations of positional and structural changes, functional orthotics are an appropriate treatment modality. Even when associated with a painful medial lump or bunion, the deformity progression and symptomology may be arrested with a functional orthotic and appropriate shoe gear. However, once the deformity has progressed to the stage where bowstringing of the flexor hallucis longus and extensor hallucis longus have initiated an increase in the intermetatarsal angle, then orthotics alone will not control the deformity, and surgical correction and orthotics and/or digital orthoses are indicated.
A symptomatic Tailor’s bunion most frequently will respond well to conservative therapy when a patient has either a rigid or flexible forefoot valgus deformity, with a relatively normal fifth metatarsal range of motion. If a functional orthotic is dispensed for this condition, the orthosis will maintain the fifth metatarsal in a supported position such that it will not be bearing abnormal weight. However, if the patient has either a compensated or uncompensated forefoot varus or a subluxed fifth metatarsal, then the orthosis will not alleviate the pathology. Although the device may reduce excessive subtalar and midtarsal joint pronation, the intrinsic foot pathology will create an overloading of the fifth metatarsal along with an aggravation of the symptoms.