The link between functional hallux limitus and a persistent foot guard tendon reflex was first proposed by the physical therapist, Sean Gibbons, in this blog post in 2016.
Functional hallux limitus is pathomechanical entity in which there is a normal range of motion at the first metatarsophalangeal joint when non-weight bearing, but during gait the joint does not dorsiflex. It may be related to windlass mechanism function
The foot guard tendon reflex is when there is a stimulus from stroking from the plantar first metatarsal head posteriorly along the medial arch towards the heel. The reflex is normal when the foot dorsiflexes in response to the stimulus (a protective response of the infant). The reflex begins in the 11-12 week in utero and is generally active from birth until around 2 years of age, though can last until 3 or 4 in some children. It is considered an important reflex to assist in gait development. Stimulation of this reflex when learning to walk would tend to offload the medial column of the foot and load the lateral column, assisting with postural stability. Reflexes are integrated with repeated use of natural movements during infancy and childhood (hence the importance of ‘play’ and sensory stimulation during this time). Sometimes the primitive reflexes persist to become what is known as unintegrated reflexes.
What Gibbons suggests is the cause of what appears clinically as functional hallux limitus is a persistence of the foot guard tendon reflex. If the foot guard tendon reflex does not integrate and persists, then there is assumed to be a tendency for the load to be more on the lateral the lateral column of the foot more as stimulation of the medial column from the ground initiates the reflex. This also tends to be the weight-bearing pattern seen in functional hallux limitus (but this is traditionally assumed to be a more lateral centre of pressure as body weight moves forward to move around the assumed functional block at the first metatarsophalangeal joint). If this hypothesis is correct, then the management of functional hallux limitus is the use of integrating exercises. The ‘reflex’ initiated dorsiflexion (or inhibition of plantarflexion) of the first ray (medial column) would limit first metatarsophalangeal joint dorsiflexion, theoretically producing a functional hallux limitus.
- there is no evidence to support this; no studies have been done; it is just an alternative explanation for the phenomenon of functional hallux limitus that is not very compelling, though not implausible
- the whole basis of unintegrated primitive reflexes is something of a fad with not a lot of convincing evidence supporting it
- some of the exercises suggested for integrating the reflex could, at a stretch, be similar to the manipulation that is advocated by some for functional hallux limitus. This may account for the clinical success of the above hypothesis or the success of the putative manipulation for the functional hallux limitus could be due to the integration of the reflex
- it could be assumed that this reflex is mediated by contraction of the tibialis anterior muscle to elevate first ray/medial column; this is something that is generally not notced in those with functional hallux limitus
- Gibbons also suggests that idiopathic toe walking could also be due to the persistence of the same reflex
Is the persistent ‘foot guard tendon reflex’ the cause of functional hallux limtus? (Podiatry Arena)
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