We need to do physical therapy

We need to do physical therapy. They need to strengthen the posterior tibial tendon, as I said before, that is the tendon that is going to help support the arch. They also need to work on the peroneus longus tendon. As we get later in the talk, the peroneus longus tendon runs along the lateral border of the foot, it then runs under the arch of the foot to attach to the base of the first metatarsal, so you can imagine if that tendon pulls hard, if there is active contraction, it’s going to pull the first metatarsal down, so it’s going to bring that first metatarsal head down which is going to bring the arch up. So those are the things that I write on my physical therapy prescription for someone that first comes to see me with hallux valgus problems and arch problems.

The other thing is, appropriate shoe wear. They have to be in shoes that fit the shape of their foot. When someone has a hallux valgus deformity, they are very wide through here. They tend to get shoes that narrow and taper here so that there is rubbing over the bony prominence here, the rubbing out here on the distal aspect of their toe and they are also starting to have pain over here because the baby toe and fifth metatarsal head are rubbing in the shoe. This is somebody that needs a shoe with a square toe box. They also need a shoe with a high toe box if the second metatarsal is popping up, you need to have room so it doesn’t rub on the top of the shoe, and this can be a hard thing to convince the patient of. When I see a lady that comes in with shoes like that, there is absolutely no way I am going to convince her to wear shoes like this. So, hammertoes, metatarsalgia, forefoot pain under the metatarsal heads, what is going on here, well they are going to come and tell you, my toes are all curled up and they don’t touch the ground.

This is as though we are looking up on the foot here, but as you can see, there is the toe, it’s like no rest of the toe, you are just seeing the toe pulp on the end here because his toes are all curled up, and again, it rubs against the top of their shoe. They have that painful callous over the PIP joint of each lesser toe, and they sometimes tell you, well when I’m walking in the bathroom or on my kitchen floor on a really hard surface, it feels like I’ve got rocks under the balls of my feet. It may not project well but there is a large diffuse callous there over the lesser metatarsal heads here and here. So what’s happening, there is mechanical overload of the MTP joint. Often I see hammertoes and metatarsalgia in association with people with hallux valgus. Remember, that hypermobile first ray. So if the first ray doesn’t carry it’s share of the weight bearing load, it’s going to go to the adjacent metatarsals. There is also a tendon imbalance. The flexor tendons on the plantar aspect of the foot become contracted. They pull the toe down, the extensor tendons which work across the MTP joint, they are pulling the toe up, so they are going from having straight toes to having toes that curled up like this, because the tendons are over pulling through their respective joints and curling the toe up.

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