When is the Cluffy Wedge® indicated?
When is the Cluffy Wedge® indicated?
When is the Cluffy Wedge® indicated? Anytime First-MTPJ motion clinically appears restricted, the Cluffy Wedge® is an excellent selection applied to an orthotic, insole or footwear. Please see the indications list for more specific recommendations. Can the Cluffy Wedge® be applied in all shoe gear? You will have to choose a shoe that has enough room in the toe box to accommodate elevation of the big toe. Dress shoes, as a general rule, will not work with the Cluffy Wedge®. Can the Cluffy Wedge® be moved from one shoe to another? You should not actually remove the Cluffy Wedge® from an insole or shoe, as the glue strip will become ineffective. However, an insole can usually be moved from one shoe to another rather easily. Where do I purchase the Cluffy Wedge®? Check the list of dealers under “Purchase” on this website. Cluffy Biomedical maintains a list of “Retail Affiliates”-- please call us so we can direct you to an affiliate in your area. Cluffy Biomedical sells in quantities of 24 or more pairs at a time. Will my doctor understand how the Cluffy Wedge® works? Have your doctor view the video clips of how the Cluffy Wedge® works on the website if they are not familiar with the product. How long will the Cluffy Wedge® last? The Cluffy Wedge® is made out of a high durometer EVA foam material. It will bottom out over time and needs to be replaced as soon as wear becomes sufficient to minimize the elevation of the wedge. As soon as the Cluffy Wedge® loses its effectiveness, it should be replaced. Time frames for replacement will vary depending on your weight and activity level. Can I use the Cluffy Wedge® if I do not have functional hallux limitus? Yes, the Cluffy Wedge® will have no adverse effects on the foot even if functional hallux limitus is not present. Are there any contraindications to using the Cluffy Wedge® If you are diabetic and have peripheral neuropathy (a lack of sensation in the feet), you should use the Cluffy Wedge® only under medical supervision. If you have a lack of feeling in your feet for any other reason, you should use the Cluffy Wedge® only under medical supervision. Thick toenails may cause an irritation of the big toe as it hits the toe box of the shoe. Thinning of the nail is advised in these circumstances. Do not use the Cluffy Wedge® if you have a structural limitation of motion of the big-toe joint or if you have a rigidly plantarflaxed first ray. Are there any people who cannot tolerate the Cluffy Wedge®? There is a small percentage of people that will not tolerate the correction of the Cluffy Wedge®. If the wedge is improperly applied or if the shoe gear is inadequate, then the Cluffy Wedge® will be either ineffective or uncomfortable. The Cluffy Wedge® can be easily removed if it cannot be tolerated. How is the Cluffy Wedge® different than a first-ray cutout or reverse Mortons extension? A first-ray cutout or a reverse Mortons extension uses a depression under the first metatarsal head to allow the first metatarsal to plantarflex into the ground. The first-ray cutout may allow the foot to pronate more in late midstance as it moves the most medial aspect of the front of the orthortic laterally. While this may improve first- metatarsal head weight bearing, it may also pronate the entire foot structure and jam the first ray. The reverse Mortons extension puts a buildup under metatarsals 2-5, which is a pronatory force on the foot axis. The overall effect will be the same as a first-ray cutout, increasing first-metatarsal weight bearing ahead of preloading the hallux, potentially jamming the first MTPJ. A Cluffy Wedge® preloads the hallux in dorsiflexion, which promotes unrestricted motion of the first MTPJ. As a result of dorsiflexion of the hallux, plantarflexion of the first metatarsal results. This promotes rearfoot supination at a time in the gait cycle when this is critical. There is no relative buildup under metatarsals 2-5 and significant off-loading of the forefoot can be achieved in propulsion. This correction does not bias the foot medially and is the only correction, possibly improving first-MTPJ motion, which is critical to normal foot function. This is the only orthotic correction that functions into propulsion. How is the Cluffy Wedge® different than a Kinetic Wedge? The Kinetic Wedge is essentially a cutout under the first metatarsal head and has all of the inherent disadvantages of a first-ray cutout. Loading the first metatarsal before pre- loading the hallux will not necessarily improve first MTPJ motion. First-MTPJ dorsiflexion is the most physiologic method of improving first-met head weight bearing, while promoting normal body mechanics. What do you recommend when the toe hits the toe box of the shoe despite having plenty of room in the shoe? One of the complaints we hear occasionally with the Cluffy Wedge® is that the big toe hits up against the toe box of the shoe and causes a pressure point, not allowing the client to use the wedge comfortably in their shoe. We have seen this occasionally in our own hands, even though the shoe has plenty of room for the wedge and the toe. When the toe box of the shoe is too narrow the problem is obvious. When the toe box has plenty of room the problem is less obvious. What we have found is the compensation most likely from limited dorsiflexion of the first MTPJ is early knee and hip flexion. The net result of this is decreased ankle plantarflexion in propulsion. (This, by the way, is the main cause of Achilles tendon pathology.) In order for the ankle to plantarflex less the dorsiflexors of the ankle have to work harder. These are the Anterior Tibial tendon (AT), which will serve to elevate the first ray and further jam motion of the first MTPJ, the Extensor Hallucis Longus (EHL), which is responsible for elevating the hallux, and the extensor digitorum longus (EDL), which elevates the lesser toes and dorsiflexes the ankle. In addition to this all of the hip flexors are also activated prematurely. Once the Cluffy Wedge® is applied and the first MTPJ is unlocked, the ankle is allowed to plantarflex more as the first MTPJ dorsiflexes. This can have significant therapeutic benefits for the Achilles tendon, among other things. However, we often find that the compensatory gait strategies are still present to some degree. These are based in neurological pathways that take some time and gait training to reverse, in some cases. But that is precisely why the hallux continues to dorsiflex and press on the toe box of the shoe. We have found that some people only experience this problem for a short time. As the new gait pattern is learned the hallux no longer has to dorsiflex as much and the pressure goes away. In others the problem is more persistent. Your timely advice in these situations will fix the problem. You need to tell these folks to think as if they are rolling off the ball of their foot, and at the same time tell them to push down gently on the Cluffy Wedge® to feel the wedge in their shoe. This is something they will have to think about for a little while, then it will become a new habit and they will no longer have to concentrate to do this. This simple step makes all the difference in the world and allows everyone who needs the wedge to wear it, and just takes a few minutes of your time. How is the Cluffy Wedge different than a Mortons Extension? The Mortons' Extension is a build up under the first metatarsal that is recommended to improve weight bearing when a short first metatarsal is present, with an associated lack of weight bearing. One of the consequences of this, is excessive weight distribution under metatarsals 2 and 3 and 4 ( metatarsalgia) as well as many other foot pathologies and deformities. This method of dealing with a lack of weight bearing under the first metatarsal has been popular for a number of years and dates back to the writings of Dudley Morton in the 1930's, in his book entitled "The Human Foot". At the time of his writing, he did not have the important research of normal first ray function published in the 1950's by Dr. Hicks. Despite the short comings of his theory, the Mortons Extension has persisted in popularity for a number of decades. The Mortons extension increases weight bearing of the first metatarsal, but at the same time decreases motion of the big toe joint. and the associated plantar declination of the first metatarsal head. This has been studied and shown to be the case in more than one clinical trial. As the first metatarsal is elevated, motion of the big toe is restricted. As motion of the big toe joint is restricted, the stabilizing effects of the windlass mechanism are lost, and the foot never achieves stability that is necessary in propulsion. Also as the big toe is locked the body must compensate for this rigid segment, often causing postural discrepencies and structural complaints, usually in the ankle, knee, hip and lower back. The Cluffy Wedge, by contrast, is placed under the big toe, but does not extend under the first metatarsal head. The overall effect of this is much different than the Mortons extension. This is a purely physiologic method of correcting abnormal foot function and does not rely on altered weight bearing on the ball of the foot, but rather on restoring normal motion to the big toe so that the foot can function normally. When performing the functional hallux limitus test, one can appreciate the effects of the Cluffy Wedge. With slight elevation of the big toe before pushing on the first metatarsal head, all limitation of motion of the big toe joint can be overcome. As the big toe moves upward the first metatarsal always moves downward. This increases weight bearing of the first metatarsal head against the ground. The result is weight reduction on metatarsals 2, 3 and 4 and restoration of normal foot function. As motion of the big toe joint is restored the foot can assume the stable, locked position that it was meant to function in through propulsion. As normal function is restored, a sequence of events takes place to improve mechanics of the entire lower extremity and spine, reducing pain, injury potential, and improving foot efficiency and performance. The only indication for the Mortons' extension is a big toe joint with rigidity and a lack of motion resulting in forefoot pain. In this case normal motion is not achievable anyway, and as a result the first metatarsal head will often become elevated. In a normal big toe joint, with good mobility, the Mortons' extension will impair movement of this joint and impair normal foot function and is strictly contraindicated. The Cluffy Wedge is indicated anytime motion of the big toe is impaired with weight bearing, but is normal without weight bearing (functional hallux limitus). The majority ( 80-90%) of individuals presenting with foot pain will have this condition. This is the only orthotic modification that will improve big toe joint motion without compromising first metatarsal head weight bearing. In addition, this is the only orthotic modification that works into propulsion, when the orthotic no longer can effect foot function. Therefore this should be the gold standard when trying to establish normal foot function when functional limitation of big toe joint motion is impaired. Once this is achieved many foot pains are diminished and over-all foot stability and performance will be enhanced. How is the Cluffy Wedge different than a forefoot post? A varus or medial forefoot post will correct for a forefoot supination, it also will jam the first ray and limit motion of the first MTPJ. Show references for this statement. A forefoot poat actually is contraindicated if you are trying to improve motion of the first MTPJ. The Cluffy Wedge is not a forefoot post. It goes under the hallux and pre stresses the hallux in dorsiflexion and allows improved mobility of the first MTPJ. As dorsiflexion of the first MTPJ occurs, any forefoot supination will reduce and the need for the forefoot post can be eliminated. This can also be done by dorsiflexing the first MTPJ during the casting procedure and the forefoot supination can also be removed from the cast. I don’t see many patients with Hallux Limitus or Hallux Rigidus. The Cluffy Wedge is not specifically indicated for Hallux Limitus or Rigidus. When there is arthritis in the joint it is not wise to promote additional motion in the joint. There are, however, good results with hallux rigidus, as the wedge brings the first MTPJ to its end range of motion and prevents additional motion from occurring. When motion occurs, this results in a jamming of the first MTPJ is dorsiflexion. When this jamming is eliminated, pain often subsides. The real application of this is in functional hallux limitus, which will be present in the vast majority of the patients you treat. About 80-90 % of your patients will have this condition according to research we are currently conducting. If you would like we can set up a meeting on gotomeeting.com to review with you how to check for this condition. Once you learn to identify this condition you will appreciate the pervasiveness of this problem and your outcomes will improve as you treat the foot more effectively, addressing all of the elements of the pathology.