Tag Archives: dynamic splinting

Dynamic Splinting for Hallux Valgus and Hallux Varus: A Pilot Study

by Mathew M. John, DPM1, F. Buck Willis, PhD2

The Foot and Ankle Online Journal 3 (1): 1

Background: Hallux Abductovalgus (HAV) is a deformity causing excessive angulation of the great toe towards the second toe, and this condition affects over 3.6 million Americans. Conversely hallux varus is excessive medial deviation and this pathology occurs secondary to procedures correcting hallux valgus and as a pediatric/congenital anomaly. The purpose of this pilot study was to report the benefits that Dynamic Splinting (DS) had on reducing contracture in hallux varus and hallux valgus.
Methods: Ten patients treated with DS were examined and these patients included six diagnosed with HAV and four patients diagnosed with hallux varus. The outcome measures reported include changes in maximal, active range of motion (AROM) and resting alignment.
Results: The patients treated for HAV regained a mean 10° active range of motion (AROM) in one month. The patients treated for hallux varus regained a mean 9° AROM in 3 months.
Conclusions: Dynamic splinting was beneficial for all patients in this study. The HAV patients regained a mean 10° of AROM (mean duration 1 month) and the hallux varus patients gained a mean 9° (mean duration 2 months). The modality which delivered low-torque stretching for prolonged durations was effective in reducing these conditions without requiring surgery.


Key words: Contracture reduction, Dynasplint, home therapy, rehabilitation.

Accepted: December, 2009
Published: January, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0301.0001

Hallux Abductovalgus (HAV) is a bunion deformity causing abnormal angulation of the great toe towards the second toe. The incidence rate of HAV is 1% of all Americans[1-4] and this includes 9% of women over the age of 60 years old. This pathology causes pain, inflammation, and reduced or impaired functioning of the hallux in ambulation.

The current standard of care in treating this condition includes nonsurgical treatment such as shoe modification followed by surgical management. [5-8] Complications of surgical treatment are not without risk though. Osteotomies of the first metatarsal such as the Lapidus and distal chevron procedure have caused significant incidence of hallux varus.

Hallux varus refers to excessive medial deviation of the great toe. In addition to the frequent iatrogenic postoperative variety, hallux varus occurs as a pediatric/congenital pathology and as a rheumatic or posttraumatic condition. [9,10] This connective tissue pathology is also currently only treated with surgical procedures. [3-6,11]

Similar pathologies have symptomatic contracture which is defined as the molecular shortening of the connective tissue and these pathologies occur from postoperative or posttraumatic arthrofibrosis [12-14], immobilization [15,16], or occur secondarily to excessive neuromuscular tone. [16,17] A study by Usuba, et. al., examined nonsurgical, therapeutic treatments for contracture that was caused by surgical immobilization in rats. [15] After 40 days of surgical immobilization the mean rat knee flexion contracture was -125° (n = 60). Usuba, et. al., then tested the interaction of four protocols: Stretching with high vs. low torque and stretching of prolonged duration vs. short duration. The only statistically significant difference seen between treatment protocols was found with combined protocols of low-torque stretching for prolonged durations.

This combination of low-torque stretching for prolonged durations is exactly what was used in the Dynasplint systems. A study by John, et. al., examined efficacy of the Dynasplint modality for reduction of contracture causing Hallux Limitus (HL). [14] In this study, 50 patients were enrolled after diagnosis of HL which occurred following a bunionectomy or cheilectomy.

The duration of this randomized study was eight weeks, and experimental patients received low-torque, prolonged stretching in the metatarsal joint Dynasplint (MTD) for 60 minutes, three times per day.

The dependent variable in Dr. John’s study was change in Active Range of Motion (AROM) and there was a significant change for the experimental patients following use of this home therapy modality (P < 0.001, T = 4.224). Experimental patients in this study regained a mean 32° change in AROM, extension compared to only a mean 10° change in AROM for control patients. Dr John’s randomized, controlled trial showed conclusive efficacy of the MTD modality.14 A retrospective study (N = 61) by Kalish and Willis showed comparable results in patients’ regaining 73% dorsiflexion at the metatarsal joint after 4 weeks. [13] The purpose of this pilot study was to report the benefits that Dynamic Splinting (DS) had on reducing contracture in hallux varus and hallux valgus.


Ten patients’ were treated with Dynamic Splinting (DS) in this report, (six with HAV and four with hallux varus). The modality can be seen in Figure 1AB and this unit delivers force and counter force to achieve elongation of connective tissue for contracture reduction. The same unit may be used for both lateral and medial stretching and this alteration is analogous to the Metatarsal Dynasplint that stretches both in plantarflexion[12] and dorsiflexion. [13,14]

Figure 1A and 1B  Hallux valgus (A) and hallux varus (B) Dynasplint.

The initial fitting for patients included customization of the unit (patient’s foot length, girth, and varying degrees of hallux edema), and training on donning and doffing of the devices. Patients also received instruction on safety, general wear and care, and standardized tension setting goals. Dynamic splinting employs the protocol of low-load stretching for contracture reduction through an appropriate biomechanical device which increases the joint’s time at end range (of motion). [12-14,16,17]

Each patient was instructed to wear the DS initially for 10 minutes, three times a day (tid) while seated, with an initial tension setting of #1 (0.10 foot pound of torque). Patients were instructed to sequentially increase the wearing time until they were comfortable wearing the unit for 60 minutes, tid. This lowest intensity was used for becoming accustomed to the system, and the patients were instructed to increase tension on increment every two weeks after they were comfortable wearing the unit for 60 minutes, tid.


The outcome measurements in this study included changes in maximal AROM for all patients and changes in hallux alignment measured in resting, weight bearing position. The patients treated for HAV regained a mean 10° AROM (one month) and the patients treated for hallux varus regained a mean 9° AROM in 3 months. Measurement of hallux alignment was taken while resting (weight bearing). This variable yielded comparable gains of Hallux abduction 10° (HAV) and 9° for adduction (hallux varus).


The purpose of this study was to report the benefits that dynamic splinting had on reducing contracture in hallux varus and hallux valgus. This examination of the new modality for contracture reduction was beneficial in restoring AROM and achieving a more optimal hallux alignment. The DS employed a proven protocol in using low-torque, prolonged stretching to reduce contracture without surgery. [13-17] While surgical resolution of hallux varus and HAV are the current standard of care, therapeutic endeavors have been prescribed effectively for treatment of post operative rehabilitation [18], and the DS used in this study answered the call for therapeutic treatment for hallux contracture pathologies. [3,6,12-14,18]

The use of dynamic splinting in this pilot study caused no adverse events, and a future randomized, controlled trial would determine if this new modality is effective in separate populations of patients with hallux abducto valgus and hallux varus.


1. Shima H, Okuda R, Yasuda T, Jotoku T, Kitano N, Kinoshita M: Radiographic measurements in patients with hallux valgus before and after proximal crescentic osteotomy. J Bone Joint Surg 91A (6): 1369 – 1376, 2009.
2. Selner AJ, Selner MD, Cyr RP, Noiwangmuang W: Revisional Am Podiatr Med Assoc 4(4): 341 – 346, 2004.
3. Miller JW: Acquired hallux varus: a preventable and correctable disorder. J Bone Joint Surg 57A (2):183 – 188, 1975.
4. Lui TH: Technique tip: minimally invasive approach of tendon transfer for correction of hallux varus. Foot Ankle Int 30(10): 1018 – 1021, 2009.
5. Miller RJ, Rattan N, Sorto L: The geriatric bunion: correction of metatarsus primus varus and hallux valgus with the Swanson total joint implant. J Foot Surg 22 (3):263 – 270, 1983.
6. Vanore JV, Christensen JC, Kravitz SR, Schuberth JM, Thomas JL, Weil LS, Zlotoff HJ, Mendicino RW, Couture SD; [Clinical Practice Guideline First Metatarsophalangeal Joint Disorders Panel of the American College of Foot and Ankle Surgeons]: Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 3: Hallux varus. J Foot Ankle Surg 42 (3): 137 – 142, 2003.
7. Orzechowski W, Dragan S, Romaszkiewicz P, Krawczyk A, Kulej M, Morasiewicz L: Evaluation of follow-up results of McBride operative treatment for hallux valgus deformity. Ortop Traumatol Rehabil 10(3): 261 – 273, 2008.
8. Jahss MH: Disorders of the hallux and first ray. Disorders of the Foot and Ankle: Medical and Surgical Management. 2nd ed. Philadelphia, Pa: WB Saunders Co, 1084 – 1089, 1991.
9. Trnka HJ, Hofstaetter SG, Easley ME: Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. Surgical technique. J Bone Joint Surg 91A (Suppl 2 Pt 1): 156 – 168, 2009.
10. Oloff LM, Bocko AP: Application of distal metaphyseal osteotomy for treatment of high intermetatarsal angle bunion deformities. J Foot Ankle Surg 37(6): 481 – 489, 1998.
11. Bilotti MA, Caprioli R, Testa J, Cournoyer R Jr, Esposito FJ: Reverse Austin osteotomy for correction of hallux varus. J Foot Surg 26 (1): 51 – 55, 1987.
12. John MM, Willis FB, Portillo A: Dynamic splinting for runner’s toe: a case report with gait analysis. J Am Podiatric Med Assoc 99(4): 367 – 370, 2009.
13. Kalish SA, Willis FB: Hallux limitus and dynamic splinting: a retrospective series. The Foot & Ankle Online Journal 2 (4): 1, 2009.
14. John MM, Kalish SR, Perns SV, Willis, FB. Dynamic Splinting for Hallux Limitus: a Randomized, Controlled Trial. Journal American Podiatric Medical Assoc (In-Press)
15. Usuba M, Akai M, Shirasaki Y, Miyakawa S: Experimental joint contracture correction with low torque -long duration repeated stretching. Clin Orthop Relat Res 456: 70 – 88, 2007.
16. Willis FB: Post-TBI Gait rehabilitation. Applied Neurol 3(7): 25 – 26, 2007.
17. Lai J, Jones M, Willis B: Effect of dynamic splinting on excessive plantar flexion tone/contracture: A controlled, cross-over study. Proceedings of the 16th European Congress of Physical and Rehabilitation Medicine. Minerva Medica pubs, Italy, 106 – 109, August, 2008.
18. Schuh R, Hofstaetter SG, Adams SB Jr, Pichler F, Kristen KH, Trnka HJ: Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase. Phys Ther 89(9): 934 – 945, 2009.

Address correspondence to: University of Phoenix: Axia College, Adjunct Professor Health Sciences and Dynasplint Systems, Clinical Research Director.
Email: BuckPhD@yahoo.com

Ankle & Foot Centers 2790 Sandy Point Rd. #300 Marietta GA, 30066. (770) 977-3668.
University of Phoenix: Axia College, Adjunct Professor Health Sciences, Dynasplint Systems, Clinical Research Director , PO Box 1735 San Marcos TX 78667 (512) 297-1833

© The Foot and Ankle Online Journal, 2010

Hallux Limitus and Dynamic Splinting: A Retrospective Series

by Stanley R. Kalish, DPM, FACFAS1 , F. Buck Willis, PhD2

The Foot and Ankle Online Journal 2 (4): 1

Hallux limitus (HL) is commonly seen following contusions or surgical procedures at the metatarsal joint of the great toe. The purpose of this retrospective study was to examine dynamic splinting for treating HL. Sixty-one cases were examined to measure difference between HL from contusion, bunionectomy, or cheilectomy. After a mean duration of 4.2 weeks in treatment with the metatarsal dynasplint (MDS), there was a significant change for all patients (P<0.0001) with a mean 73% gain in dorsiflexion at the metatarsal joint. The lack of difference between groups (P>0.005) shows the consistent benefit of MDS for HL contracture reduction.

Key words: Hallux limitus, dynamic splinting, first metatarsophalangeal joint

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: March, 2009
Published: April, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0204.0001

Onset of Hallux Limitus (HL) commonly affects patients after contusion injuries and after one of the two most common surgical procedures for foot pathologies, a bunionectomy or a cheilectomy. [1-3] HL is a pathology of degenerative arthritis in the first metatarsophalangeal joint (MTJ) of the first toe, or a consequence of a runner’s injury this pathology affects both adolescents and adults. [2-8] The literature consensus has long assumed that pain reduction is a predictable result of properly selected surgical patients, but that improvement in the arc of functional motion about the great toe should not be expected.

Before HL repair with cheilectomy, radiographs typically reveal osteophyte formation in addition to dorsal exostosis, narrowing of the joint space, subchondral sclerosis, and flattening of the metatarsal head. Osteophyte formation is common on the first metatarsal head (both plantar and dorsal sides) causing inflammation, edema, pain, and reduced range of motion (ROM). Action of the hallux requires plantarflexion of the first metatarsal bone, which allows the proximal phalanx to dorsiflexion. This bidirectional hinge action must occur with each step. [8,9] The normal smooth motion of the proximal phalanx over the head of the metatarsal is disrupted leading to painful compression of the phalanx against the head of the metatarsal as the joint is dorsiflexed.

Standard of care for HL includes orthoses, NSAIDs and home stretching exercises, but these protocols have had limited success in regaining range of motion because the stretching was not biomechanically correct and did not have measurable, dynamic tension.

The procedure of utilizing low-load, prolonged-duration stretch has been effective in reducing contracture in similar conditions of reduced ROM [3,12,13]  because it does have biomechanically appropriate alignment with measurable tension. Dynamic splinting used the protocol of low-load, prolonged-duration stretch to achieve significant time at their end range of motion. As the range of motion progresses, the calibrated tension of the dynamic splint is increased to continue stretching at the end range. The purpose of this retrospective cohort study was to examine the efficacy of dynamic splinting for treating HL.



Case histories were retrospectively acquired for 61 patients who had been diagnosed with HL which continued following contusion or surgery. These patients were treated for one or more months with dynamic splinting.


Patients’ initial introduction to the Metatarsophalangeal Dynasplint System (MDS) [Dynasplint Systems, Inc., Maryland, USA], included customized fitting (patient’s foot size and varying degrees of hallux edema) and training on donning and doffing of the devices. (Fig. 1) Verbal and written instructions were provided throughout the duration of treatment for safety, general wear and care, and tension setting goals based on patient tolerance.

Figure 1   Metatarsophalangeal Dynasplint Extension System.

Each patient was instructed to start wearing the MDS initially for 30 minutes, three times a day while seated at a tension setting of #1 (0.10 foot pound of torque). This frequency, intensity, and duration were for acclimatization to the system. The patients were then instructed to increase each wear by ten minutes each day (i.e. 30 min tid (three times a day, latin for ter in die), 40 min tid, 50 min, tid, 60 min tid), until he/she was comfortable wearing the unit for a total of 3 hours each day.

After each patient was comfortable wearing the unit for a total of 3 hours per day, for three days, the patient was instructed to increase the tension one increment every week until reaching setting #4 (0.7 foot pounds of torque). If excess fatigue followed a session (soreness for more than 15 minutes) the patient was instructed to decrease the tension one half a setting for two days until comfortable wearing for 60 minutes per session and then recalibrate at the higher setting. Tracking of patient compliance was accomplished with a dairy, which was submitted to the attending clinicians monthly.


The dependent variable in this study was the change in dorsiflexion at the metatarsal joint of the great toe, and the independent variables were the patient categories of bunionectomy vs. cheilectomy vs. contusion. Statistical data analysis was accomplished using a one-way analysis of variance (ANOVA) on data collected after one month’s use of the MDS.


After a mean duration of 4.2 weeks, the ANOVA showed a significant change for all groups (N=61, P<0.001, T=30.079, DF=60). However, there was not a significant difference between groups (P>0.05). (Fig. 2)

Figure 2  Changes in MTJ Extension.


The cause for postoperative contracture is hypothesized to be due to excess arthrofibrosis and position due to pain. [10] Secondary treatment procedures include surgical realignment as done with the Kalish Osteotomy. If mobility is not regained and pain is not reduced, then arthrodesis is considered as a final salvage procedure. [11] However, a non-invasive procedure for contracture reduction is usually more desirable. A pilot study recently showed the efficacy of dynamic splinting for regaining flexion in the great toe [3], but this is the first study to examine changes in hallux extension, dorsiflexion at the metatarsal joint, following dynamic splinting.

The purpose of this retrospective cohort study was to examine the efficacy of dynamic splinting for treating hallux limitus. Dynamic splinting used as a home therapy, provided an additional 90 hours per month of stretching at end range for each patient. This was accomplished with controlled, calibrated, changeable tension which adapted to gains in ROM, keeping the joint at end range.


This retrospective cohort study showed a statistically significant difference in ROM following use of the MDS (P < 0.0001), with patients gaining a mean 73% increase in dorsiflexion at the metatarsal joint of the great toe in just one month. MDS utilizes a biomechanical adaptation to achieve a physiological change in contracture reduction of the connective tissue. Patients in this study received a mean 90 hours of end range stretching in home therapy resulting in regained ROM, eliminating the need for secondary surgical procedures to reduce the contracture. [11]


1. Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int 27(11):869 – 76, 2006.
2. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc 31: S448 – 58, 1999.
3. Willis B, John M. Dynamic Splinting Increases Flexion for Hallux Rigidus (Pilot Study). Biomechanics 14(9), pg49 – 53, 2007.
4. Brodsky JW, Baum BS, Pollo FE, Mehta H. Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus. Foot Ankle Int. 28(2):162 – 5, 2007.
5. Talarico LM, Vito GR, Goldstein L, Perler AD. Management of hallux limitus with distraction of the first metatarsophalangeal joint. J Am Podiatr Med Assoc 95(2):121 – 9, 2005.
6. Payne C, Chuter V, Miller K. Sensitivity and Specificity of the Functional Hallux Limitus Test to Predict Foot Function. J Am Podiatr Med Assoc 92: 269 – 271, 2002.
7. Kennedy JG, Chow FY, Dines J, Gardner M, Bohne WH. Outcomes after interposition arthroplasty for treatment of hallux rigidus. Clin Orthop Relat Res 445:210 – 5, 2006.
8. DeFrino PF, Brodsky JW, Pollo FE, Crenshaw SJ, et al: First metatarsophalangeal arthrodesis: a clinical, pedobarographic and gait analysis study. Foot Ankle Int 23(6): 496 – 502, 2002.
9. Canseco K, Long J, Marks R, Khazzam M, Harris G. Quantitative characterization of gait kinematics in patients with hallux rigidus using the Milwaukee foot model. J Orthop Res 30, 1 – 9, 2007
10. Becher C, Kilger R, Thermann H. Results of cheilectomy and additional microfracture techniques for the treatment of hallux rigidus. Foot Ankle Surg (10): 155-160, 2005.
11. Lau JT, Daniels TR: Outcomes following cheilectomy and interpositional arthroplasty in hallux rigidus. Foot Ankle Int 2001 22 (6): 462 – 70, 2001.
12. Hepburn, G. Contracture and Stiff Joint Management with Dynasplint. J Ortho Sports Phys Ther 8 (10): 498 – 504, 1987.
13. Willis B. Dancers restore knee flexion through dynamic splinting. Biomechanics 15 (1), 49 – 54, 2008.


The authors thank Dr. Ram Shanmugam, biostatistics professor at Texas State University, San Marcos, TX for performing statistical analysis.

Conflict of Interest

Regarding conflict of interest, no extramural funding was used in this study. Dr. Kalish is an educator for the parent company of Dynasplint Systems and he did not receive any funding for this study. Dr. Willis is employed by Dynasplint Systems, Inc. and has no ownership or stock in this company.


Dynasplint® Systems, Inc.
770 Ritchie Highway, Suite W21
Severna Park, MD 21146

SPSS Inc. (Base Statistical System)
233 S. Wacker Drive, 11th floor
Chicago, IL 60606-6307

Address correspondence to: F. Buck Willis, PhD
Email: BuckPhD@yahoo.com

1  Atlanta Foot and Leg Clinic, P.A.
2  Texas State University (at the time of this study) and corresponding author. Dynasplint Systems Clinical Research.

© The Foot and Ankle Online Journal, 2009