Emerging Insights On First Ray Hypermobility | Podiatry Today 9/23/18, 5*52 PM

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Emerging Insights On First Ray Hypermobility

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Current And Emerging Concepts With First MP
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(/files/docs/pt12hypermobility1.jpg)Hypermobility of the first ray is a Current Issue

critical component in addressing hallux valgus. Accordingly, these
authors examine the research on assessing hypermobility and discuss September 2018
pertinent considerations in achieving optimal surgical correction while
Current And Emerging
preventing recurrence. Concepts With First MPJ
Implants (/current-and-
There has been wide ranging discussion on the e!ect of hypermobility emerging-concepts-
in the development of hallux valgus, what we consider normal versus first-mpj-implants)

pathologic and the role this plays in determining the appropriate treatment. At the
foundation, there is controversy over how to measure hypermobility in both static and
dynamic states, and in what plane. A previous review of the literature brings to light the
di!iculties of assessing and treating hypermobility, and the wide range of theories.1 (/issue/volume-31-issue-9-
september-2018)
Accordingly, we would like to review current concepts regarding hypermobility and the Current Issue ▶ Issue Archive
importance of this factor in the correction of a hallux abducto valgus (HAV) deformity.
We will also discuss the significance of rotation of the first metatarsal in the frontal TODAY'S TOP STORIES
plane and how this may be altering our perception of where the abnormal motion is
When An Adult Patient Presents With Red
actually occurring.
Spots On The Feet (/article/7496)

When Vitamin And Nutritional Deficiencies

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The role of the first ray in gait is to create a stable support for propulsion so the body is When Vitamin And Nutritional Deficiencies
Cause Skin And Nail Changes (/when-vitamin-
able to move forward e!ectively.2 Root and colleagues described hypermobility of the
and-nutritional-deficiencies-cause-skin-and-
first ray as an abnormal dorsiflexion motion in response to ground reactive forces. nail-changes)
Although the vast majority of pathologic motion is usually in the sagittal plane, Root
Diagnosing And Treating Insect Bites And
correctly described the motion as triplane motion with the metatarsal rotating in a Stings On The Lower Extremity (/diagnosing-
valgus direction. Root and colleagues believed that hypermobility was either and-treating-insect-bites-and-stings-lower-
congenital or acquired, and that acquired hypermobility was a result of pronatory extremity)
forces of the foot.3 To reinstate a stable construct for propulsion and concurrently treat A Guide To The Di!erential Diagnosis Of Heel
the hallux abducto valgus (HAV) deformity, a tarsometatarsal joint fusion may be Pain (/a-guide-to-the-di!erential-diagnosis-of-
indicated when hypermobility of the first ray is visible upon evaluation of a patient.4 heel-pain)

How Our Understanding Of Hypermobility Has Evolved A Guide To Treating Ankle Sprains From Start
To Finish (/article/5836)
There has been a tremendous amount of research dedicated to studying hypermobility.
Roukis and coworkers reviewed 70 papers in 2003 and did not find a consensus
regarding the measurement of normal or abnormal first ray range of motion, planes of Interactive Poll
mobility, or techniques of measurement.1

Since 2003, our understanding of hypermobility has led to the conclusion that other
bones besides the first metatarsal and medial cuneiform may contribute to this When do you start weightbearing
condition. Fusion is frequently necessary to control excessive motion but can also your Lapidus bunionectomy patients
compensate for malpositioning of the first metatarsal. In other words, simply locking postoperatively?
the metatarsal cuneiform joint may not be su!icient to correct the excess motion and
Immediately
eliminate the deformity. Hypermobility throughout the Lisfranc joint, ine!ective
1–2 weeks
dynamic locking of the entire medial column and inadequate tendon and ligament
2–4 weeks
integrity may contribute greatly to collapse of the arch and excessive motion,
4–6 weeks
particularly in stance and propulsive phases of ambulation.
6 weeks or later
A study by Kamanii and colleagues looked at 20 people who were diagnosed with joint
hypermobility syndrome according to Beighton and Bulbena score models.5,6
VOTE
Comparing these people to 20 healthy controls, the researchers obtained
weightbearing anteriorposterior (AP) and lateral radiographs, and assessed 11 angles.
The authors found a statistically significant di!erence in calcaneal pitch and
tarsometatarsal angles on lateral radiographs, and the first metatarsophalangeal joint FEATURED ARTICLE
(MPJ) angles on AP radiographs. From their data, the study authors suggested that A Critical Look At
people with hypermobility were predisposed to having a pes planus foot type and HAV Readmissions For Patients With
deformities. Diabetic Foot Infections
(/critical-look-readmissions-
(/critical-look-
(/files/docs/pt12hypermobility2.jpg)King and Toolan compared 15 patients-diabetic-foot-
readmissions-
infections)
healthy people without HAV to 25 individuals who failed conservative patients-diabetic-
By Kenneth R. King, DPM, and David C
treatment for HAV.7 The investigators compared clinical evaluations foot-infections) Hatch, Jr., DPM, AACFAS | Reads:
between the two groups for hypermobility. They determined
hypermobility using two methods. They assessed dorsiflexion of the first
TRENDING TOPICS
ray relative to the lesser rays with manual dorsiflexion force and
subsequently assessed overloading of the second ray as determined by Sesamoid (/topics/sesamoid-0)
a plantar hyperkeratotic lesion. Researchers evaluated weightbearing Dermatology (/topics-27)
AP and lateral radiographs for both groups to compare the distal Nutrition (/topics/nutrition)
metatarsal articular angle, intermetatarsal angle, MPJ angle, talonavicular coverage Nerve Entrapment (/topics/nerve-entrapment)
and the talo-first metatarsal angle. On the lateral radiographs, the study authors Jones Fracture (/topics-35)
assessed the lateral MPJ angle, the talo-first metatarsal angle and Meary’s angle.

The authors also evaluated two new parameters for measuring hypermobility on the
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lateral radiographs.7 The first was the perpendicular distance between the plantar
aspect of the medial cuneiform and the plantar aspect of the first metatarsal. The Podiatry Today

second technique was to measure the angle formed by the medial cuneiform and first @PodiatryToday

metatarsal articular surface, extending from the superior to the inferior aspect of the New DPM Blog by Richard Blake, DPM: Recovering
From A Sesamoid Fracture: Keys To Facilitating A
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Return To Shoes After Wearing A Walking Boot

joint. All the patients with HAV had clinical signs of hypermobility. In comparing tinyurl.com/ya2hs4c2 @APMA @ACFAS

patients with HAV to healthy people, the study findings revealed statistically significant
di!erences in the distal metatarsal articular angle, the intermetatarsal angle, the MPJ
angle, talonavicular coverage, the lateral talo-first metatarsal angle, the dorsal
translation of the first metatarsal, the medial cuneiform/first metatarsal articular angle,
and the lateral MPJ angle.

King and Toolan concluded that there was a correlation between radiographic and Sep 21, 2018

clinical testing for hypermobility as well as an indication for lateral imaging in

Podiatry Today
determining hypermobility.7 They suggest that measurement of the dorsal translation of @PodiatryToday

the first metatarsal and the medial cuneiform/first metatarsal articular angle could New DPM Blog by Jeffrey D. Lehrman, DPM,

represent “quantifiable radiographic measures” for defining hypermobility. FASPS: Imminent ICD-10-CM Changes You Need

Glasoe and coworkers compared two devices that both measure first ray motion in the CLASSIFIEDS
sagittal plane.8 Both are similar in that they apply a force against the plantar first
Wound Care Medical Director
metatarsal and measure the dorsal translation from a probe at the dorsal aspect of the
(https://healthjobconnect.com/job/193/wound
first metatarsal. The Klaue device applies a manual force and the Glasoe device care-medical-director/)
applies a quantifiable force using a screw mechanism. In this study involving 40 at-risk
patients, the authors found that the average dorsal translation was 5.2 (±1.5) mm with
the Klaue device and 4.9 (±1.6) mm with the Glasoe device. The authors did not find a ONLINE CME
statistically significant di!erence in measurements between the two devices and
Modern Techniques to Manage Infected
determined each device was able to detect significance within 1 mm. Wounds in the Diabetic Patient: Integrating
Advanced Technologies to Optimize Healing
The study authors concluded the Klaue device was appropriate for clinical
(https://www.naccme.com/program/2016-667-
investigators while the Glasoe device was better for studies requiring specific force 11)
measurements.8 The researchers also concluded that 8 mm of motion may be a
Biologically Clearing the Barriers to Wound
threshold for hypermobility as it is two standard deviations greater than the at-risk Healing: Changing the Wound Healing
population they examined. Environment through Debridement
(https://www.naccme.com/program/2016-667-
(/files/docs/pt123hypermobility3.jpg)In a study assessing methods of 2b)
measuring hypermobility, Kim and colleagues compared the Eulji
Protocols for the Prevention and Treatment of
Medical Center (EMC) device to two well-known alternative methods.9
Pressure Injuries: Sustaining Outcomes at the
The EMC device consists of two separate “L” shaped objects with the Point of Care
first being a measuring device held on the dorsal aspect of the second (https://www.woundcme.org/program/2017-
751)
ray and the second component held over the first ray. The first ray
component lined up next to the measurement guide component on the
second ray so researchers could measure the movement in millimeters
Podiatry Today
before and after manual dorsiflexion of the first ray. The study authors 9,540 likes

compared the EMC device to the Coleman block method in 69 feet and the Klaue
device in 46 feet. There were significant di!erences in measurements between the
EMC device and Coleman block test, but the authors noted a correlation coe!icient of Like Page Share

0.84. The di!erences in measurements between the EMC device and Klaue device
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were not significant, and showed a correlation coe!icient of 0.924. Kim and coworkers
concluded that the EMC device provided a valid result and could easily assess
hypermobility.

Singh and colleagues evaluated 600 feet divided into one group of 187 feet with a HAV
deformity and one group of 413 control feet.10 On every foot, researchers measured the
first ray range of motion using the Klaue device. They altered the device to not only
obtain dorsal mobility but dorsal medial mobility as well at a 45-degree angle. The UPCOMING EVENTS
results showed that mobility in the 45-degree plane was significantly higher than in the
dorsal plane for the control group. In the HAV group, 57.8 percent of the patients were Insights and Advancements in Foot and Ankle
hypermobile in both the dorsal and 45-degree angular plane. Another 23.5 percent of Surgery (/events/insights-and-advancements-
foot-and-ankle-surgery-1)
patients in the study were only hypermobile in the 45-degree angle plane. The authors
concluded that evaluation of dorsal medial plane mobility along with dorsal mobility is APMA Region One Conference (/events/apma-
region-one-conference-4)

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preferable to only measuring dorsal plane mobility when evaluating for hypermobility. Hallux Valgus and Related Forefoot Surgery
(/events/hallux-valgus-and-related-forefoot-
Key Pointers On Managing Hypermobility surgery-2)

Each of the aforementioned studies has demonstrated that there is a wide range of Symposium on Advanced Wound Care Fall
variations in the quantity and plane of motion associated with hypermobility. In the (SAWC Fall) (/events/symposium-advanced-
wound-care-fall-sawc-fall)
presence of hypermobility, the correction of HAV generally depends on blocking
motion of the first metatarsal by holding it to a single position while the rest of the foot Windy City Podiatry Conference
retains some degree of motion. Consequently, there are many options for the (/events/windy-city-podiatry-conference-4)
correction of HAV. However, choosing the appropriate procedure for a specific patient
is critical to achieve the desired correction while preventing recurrence.
FEATURED BLOG
Coetzee and coworkers studied 24 patients (26 bunions) who had recurrence of their
Study: Diabetic Foot Complications Among The
bunion deformity after distal, shaft and proximal osteotomies.11 They found that nine Top 10 Causes Of Disability (/blogged/study-
patients had severe hypermobility and 12 had mild to moderate hypermobility. The diabetic-foot-complications-among-top-10-
authors found a disproportionate group of recurrences among those patients with causes-disability)
David G. Armstrong DPM MD PhD | Reads: 989
clinically diagnosed hypermobility. They concluded that hypermobility may be related
to a higher rate of bunion recurrence when surgeons do not address it with an
arthrodesis of the first tarsometatarsal joint.

Pentikainen and coworkers looked at 100 patients 7.9 years after a distal osteotomy
procedure.12 While 23 patients were lost to the final follow-up, the study authors found
a recurrence of deformity, which they described as a hallux valgus angle of >15
degrees, in 73 percent of the remaining patients.

However, in another study, Coughlin and colleagues found a statistically significant

reduction in first ray mobility after a proximal crescentic osteotomy and distal soft
tissue reconstruction in 103 patients (122 feet) who had moderate or severe primary
hallux valgus.13 They noted an improvement of pain on the Visual Analog Scale from a
preoperative value of 6.5 to a two-year follow-up postoperative value of 1.1. They also
noted an improvement in the American Orthopedic Foot and Ankle (AOFAS) score
from 57 preoperatively to 91 postoperatively.

(/files/docs/pt12hypermobility4.jpg)In their assessment of cadaver

models, Rush and colleagues found that when a HAV deformity was
present, dorsal drift was present with applied force due to the inability
of the windlass mechanism to activate.14 They noted that a proximal
osteotomy reduced this dorsal migration by 26 percent with realignment and
restoration of the functional stability. They concluded that hypermobility was a
symptom of the HAV deformity and one can correct it in a cadaver model without an
arthrodesis of the first tarsometatarsal joint.

From the high rate of recurrence, we can see that correction of HAV in the presence of
hypermobility is not as simple as constraining the first metatarsal in space. In fact, the
current thinking about the HAV deformity may not consider hypermobility as an
important indicator for treatment. Dayton and colleagues state that osteotomies are
mainly treating only the reduction of the intermetatarsal angle.15 They suggest that the
deformity correction should take place at the center of rotation of angulation (CORA)
as described by Paley and coworkers.15,16 The area of correction then would exist at the
metatarsal cuneiform joint and thereby not create a secondary CORA with an
osteotomy.15 Dayton and colleagues also address the frontal plane or “third plane” of
the bunion deformity by derotating the first metatarsal in the frontal plane with the first
tarsometatarsal arthrodesis.17 The frontal plane of deformity is visible on the
sesamoidal axial radiographs as a valgus rotation of the metatarsal.

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Most recently, valgus rotation of the metatarsal has become a critical element in our
understanding of the cause of HAV and the role of hypermobility. Plain radiographs
that show an elevated tibial sesamoid position imply that the metatarsal has migrated
laterally, resulting in a bowstringing e!ect of the flexor tendon. However, if one
considers the sesamoid position on a sesamoid axial view, it is apparent that the
sesamoid remains within the sesamoid grooves in contact with the metatarsal head.
Instead, the entire metatarsal rotates into a valgus position.

This brings an entirely new perspective to the term hypermobility. The rotation of the
metatarsal itself gives the impression of lateral deviation of the sesamoids on the AP
radiograph.15 Therefore, with triplanar correction of the bunion deformity at the
metatarsal cuneiform joint, one can achieve the necessary correction at the center of
rotation of angulation. By addressing the valgus rotation of the metatarsal in addition
to the increased metatarsal angle and the decreased metatarsal declination angle, the
metatarsal head appears to move into a more correct position. In many cases, this can
eliminate the need for additional soft tissue balancing such as adductor hallucis
tendon releases and lateral collateral fibular sesamoid ligament releases.15,17

The concept of metatarsal rotation raises some questions about the significance of
sagittal and transverse plane hypermobility. In order to adequately correct the
intermetatarsal angle and return the sesamoids to a functional position, Dayton and
colleagues suggest that derotation of the metatarsal with fusion of the joint is
necessary, and would inherently correct the hypermobile joint.17

In Conclusion
Hypermobility is a much more complex influence on the development of HAV than we
previously thought. In some cases, there is clearly a simple collapse of the first
metatarsal resulting in intermetatarsal splaying and medial arch collapse. However, in
other cases, one can appreciate that triplane motion dominates and simple
stabilization of the first metatarsal-medial cuneiform joint may be insu!icient. The high
rate of HAV recurrence after surgery and the complexity of the types of motion that can
occur at the first metatarsal in both stance and ambulation suggest that other forces
are in play to cause HAV. Based on these observations, it is clear that a more
comprehensive pre-surgical assessment is probably needed to predict where the
excessive motion and lack of stability is coming from.

As we gain a better understanding of the role of varus/valgus rotation of the first

metatarsal, we will become better at predicting when this motion should be limited as
well. If one can accurately determine the CORA, then a procedure such as a modified
Lapidus procedure will potentially control the sagittal plane hypermobility while
derotating the metatarsal to counter that type of malpositioning as well. As surgeons
gain a better understanding of the interactions between the sesamoid apparatus and
the first metatarsal, it is likely that the techniques used to manage hypermobility will
evolve as well.

Dr. Bohman is the Chief Podiatric Surgical Resident and an Instructor in Surgery at
Harvard Medical School. She is also a!iliated with Cambridge Health Alliance in
Cambridge, Mass.

Dr. Landsman is the Chief of the Division of Podiatric Surgery and an Assistant Professor
of Surgery at Harvard Medical School. He is also a!iliated with Cambridge Health
Alliance in Cambridge, Mass.

References

1. Roukis TS, Landsman AS. Hypermobility of the first ray: a critical review of the
literature. J Foot Ankle Surg. 2003;42(6):377-90.

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2. Valmassy RL. Clinical Biomechanics of the Lower Extremities. Mosby, St. Louis,
Missouri, 1996, pp. 22-23.
3. Root ML, Orien WP, Weed JH. Motion of the joints of the foot: the first ray. In
Root SA (ed.) Clinical Biomechanics Volume II: Normal and Abnormal Function of
the Foot, Clinical Biomechanics, Los Angeles, 1977, pp. 46-51, 350-354.
4. Catanzariti AR, Mendicino RW, Lee MS, Gallina MR. The modified Lapidus
arthrodesis: a retrospective analysis. J Foot Ankle Surg. 1999;38(5):322-32.
5. Kamanli A, Sahin S, Ozgocmen S, Kavuncu V, Ardicoglu O. Relationship
between foot angles and hypermobility scores and assessment of foot types in
hypermobile individuals. Foot Ankle Int. 2004;25(2):101-6.
6. Beighton P, Solomon L, Soskolne CL. Articular mobility in an African
population. Ann Rheum Dis. 1973;32(5):413-8
7. King DM, Toolan BC. Associated deformities and hypermobility in hallux valgus:
an investigation with weightbearing radiographs. Foot Ankle Int. 2004;25(4):251-5.
8. Glasoe WM, Grebing BR, Beck S, Coughlin MJ, Saltzman CL. A comparison of
device measures of dorsal first ray mobility. Foot Ankle Int. 2005;26(11):957-61.
9. Kim JY, Keun Hwang S, Tai Lee K, Won Young K, Seon Jung J. A simpler device
for measuring the mobility of the first ray of the foot. Foot Ankle Int.
2008;29(2):213-8.
10. Singh D, Biz C, Corradin M, Favero L. Comparison of dorsal and dorsomedial
displacement in evaluation of first ray hypermobility in feet with and without
hallux valgus. Foot Ankle Surg. 2015; epub June 10.
11. Coetzee JC, Resig SG, Kuskowski M, Saleh KJ. The Lapidus procedure as
salvage after failed surgical treatment of hallux valgus: a prospective cohort
study. J Bone Joint Surg Am. 2003;85-A(1):60-5.
12. Pentikainen I, Ojala R, Ohtonen P, Piippo J, Leppilahti J. Preoperative
radiological factors correlated to long-term recurrence of hallux valgus following
distal chevron osteotomy. Foot Ankle Int. 2014 Dec;35(12):1262-7.
13. Coughlin MJ, Jones CP. Hallux valgus and first ray mobility. A prospective study.
J(/)Bone Joint Surg Am. 2007;89(9):1887-98. Login (/user/login)

14. Rush SM, Christensen JC, Johnson CH. Biomechanics of the first ray. Part II:
Metatarsus primus varus as a cause of hypermobility. A three-dimensional Subscribe (/e-news)

kinematic analysis in a cadaver model. J Foot Ankle Surg. 2000;39(2):68-77.

15. Dayton P, Kauwe M, Feilmeier M. Is our current paradigm for evaluation and
management of the bunion deformity flawed? A discussion of procedure
philosophy relative to anatomy. J Foot Ankle Surg. 2015;54(1):102-11.
16. Paley D, Herzenber JE. Priciples of Deformity Correction, Springer-Velag, Berlin,
2005.
17. Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation
of first metatarsal to proximal articular set angle and hallux alignment in patients
undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series
and critical review of the literature. J Foot Ankle Surg. 2013;52(3):348-54.

Comments

Submitted byDoug Richie DP… (not verified) on December 06, 2015

Excellent article. However,

(/comment/11800#comment-11800)
Excellent article. However, I am confused about the assertion that the first metatarsal can rotate in a

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valgus direction in the formation of an HAV deformity. As the axis of the first ray has been firmly
established by many researchers (Hicks, Kelso and Christensen), the first metatarsal cannot rotate
into valgus unless it also plantarflexes. Are you suggesting that the first ray has moved into a plantar
flexed position in the HAV deformity in order for the first metatarsal head to rotate into valgus?
Log in (/user/login?destination=/emerging-insights-first-ray-hypermobility%23comment-form) or
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Submitted byRobert D Phill… (not verified) on December 17, 2015

This is a nice quick review

(/comment/11816#comment-11816)
This is a nice quick review of a few important studies to help understand the etiology of hallux
valgus. I would caution the authors not to accept a sesamoid axial view as proof that the first ray has
dorsiflexed and valgus rotated. This x-ray view, if taken on a standard orthoposer made for this view,
actually causes the first ray to plantarflex rather than dorsiflex. Also with hallux valgus deformity,
there is adaptation of the articular surface of the first metatarsal head when viewed on the coronal
plane as well as when it is viewed on the transverse plane. To fully settle the question of whether the
first ray varus or valgus rotates when it dorsiflexes, weightbearing CT scan technology will need to
be utilized.
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