Home Functional Hallux Limitus Conservative treatment Osteopathy
Conservative treatment
Osteopathy, reharmonizing the whole body
FHL causes disorders at multiple levels, from the foot up to the cervical spine. Osteopathy releases reversible joint blockages — the subtalar joint, the sacroiliac joints, the thoracolumbar junction — as a complement to physiotherapy, in adults and children alike.
Treatments
Harmonizing the body in the face of a global dysfunction
The purpose of osteopathy is to harmonize or reharmonize the body as a whole when a reversible dysfunction is present, whether localized or global. This discipline is suitable for patients of all ages, and FHL, through the multilevel disorders it causes, frequently warrants osteopathic intervention.
Globally, FHL causes an increased flexion moment at the knee and hip in the sagittal plane, along with a forward projection of the trunk — a mechanism well described by Dananberg in his work on gait style as an etiology of chronic postural pain.
Scientific reference
Dananberg HJ. “Gait style as an etiology to chronic postural pain”, parts 1 & 2 (Functional hallux limitus / Postural compensatory process). Journal of the American Podiatric Medical Association, 1993.
Local treatment, releasing the subtalar joint
Locally, the tenodesis effect of the flexor hallucis longus causes a blockage of the subtalar joint, which must be released to recover tendon gliding during the so-called Hoover cord maneuver. This blockage is frequently associated with a blockage of the proximal tibiofibular joint, due to the disturbance of rotational synchronism. Dysfunction of the distal tibiofibular joint may also be present as a sequela of lateral ankle sprain, and the midfoot is often subjected to excessive stresses that result in talonavicular malalignment.
Mobilization of the subtalar joint is performed in the classic manner, lying on the back or face down. The proximal tibiofibular joint is manipulated before or after the subtalar joint depending on the case, and massaging the popliteus muscle sometimes facilitates the manipulations.
Repercussions on the pelvis
Anterior pelvic tilt changes the muscular vector of the gluteus medius, bringing the piriformis into play to stabilize the pelvis when standing on one foot. Under excessive demand, this muscle develops tightness, then a shortening that limits the excursion of the sacroiliac joint. The joint, now more vulnerable, can become fixed in anterior or posterior malposition.
This dysfunction is accompanied by a compensatory blockage of the sacrum on the contralateral side, which generates a rotation of the 4th or 5th lumbar vertebra, a frequent source of pain. The patient then presents an apparent difference in leg length: this is called a “false short leg” with posterior sacroiliac dysfunction, and a “false long leg” with anterior dysfunction.
Repercussions on the back
The forward tilt of the trunk overloads the posterior musculature, the trunk erectors, which try to counterbalance the forward fall. Lordosis worsens and the lumbar segment stiffens through tightness of the iliopsoas linked to the pelvic dysfunction. The thoracolumbar junction, subjected to these stresses, is predisposed to blockage — further promoted by unilateral tendon dysfunction or in strongly lateralized patients. On examination, this blockage presents as localized muscle tightness (a trigger point) associated with limited trunk rotation.
To release the thoracolumbar junction, the osteopath uses the Fryette technique when it is fixed in rotation, or a curling-uncurling technique if it is fixed in flexion. The problem often shifts to the level above: at the last compensatory level, the second cervical vertebra, the body seeks to keep the gaze horizontal. A dysfunction is frequently found there, a source of headaches and limited cervical rotation.
Osteopathy applied to pediatrics
The presence of FHL can be detected very early in life thanks to the stretch test, which can be performed from infancy. Once walking has been acquired, an in-toeing gait is frequently associated with FHL and with pelvic dysfunction related to learning to walk and its many falls onto the buttocks.
Hindfoot manipulation, combined with daily stretches of the flexor hallucis longus performed by the parents, is very effective in giving the child steadier balance and a more harmonious gait. The child should then be followed up and the maneuvers repeated as needed. Where there is a family history of hallux valgus, early management can probably help reduce the risk of deformity.
At-risk population
In young dancers and skaters, demi-pointe training promotes hypertrophy of the flexor hallucis longus, a predisposing factor for FHL and forefoot deformity. Early screening is particularly recommended in these populations.
Understanding through video
Two lectures dedicated to the osteopathic management of FHL, presented at the 2013 and 2015 congresses.
2015 Congress — Osteopathic treatment of symptoms of FHL origin
2013 Congress — Conservative treatment: the role of the osteopath
Next pillar
Sports activities
Once the tendon has been released, relearning how to use your foot and your whole body, from Nordic walking to pivoting sports.
In practice
Role
adjunct to physiotherapy
Local target
subtalar joint
Global targets
pelvis, back, neck
Ages
all, from infancy
Dysfunctions
reversible
At-risk population
dancers, skaters