Hallux Limitus/Rigidus: Email Advice

Hi Dr. Blake!  

Thank you for this wonderful blog!  I have been dealing with an injured (and re-injured) left MTP joint for years now.  It recently felt bad enough that I sought out my GP.  X-rays showed mild-moderate 1st MTP joint degenerative disease with joint space narrowing, subchondral sclerosis & cystic changes and osteophyte formation.  I tried googling all this, but would love it if you could explain these in lay person terms. 

Dr Blake's comment: You have arthritis in your big toe joint which is causing pain. Below are some links to Hallux Limitus/Rigidus which are degrees of restricted range of motion that develop as the arthritis worsens. 

http://www.drblakeshealingsole.com/search/label/Hallux%20Limitus%2F%20Rigidus

 I have a little range of motion loss compared to the other side, but I still think it's around 60 degrees.  Am I on the road to hallux limitus? 
Dr Blake's comment: Yes, and you need to daily do the self mobilization technique in my video below. Also, if you pronate, get orthotics for your most strenuous activities. Place dancer's pads in any shoes you can. 

 My main complaints are the pain and swelling that occur after walking around with  shoes with 1" or 1-1/2" heels as well as after tap dancing.  I am currently not tapping, but would love to return to it, but am worried about irritating the joint.  Lastly, I see you mentioning dancer's pads often.  Do you have instructions on how to craft one?  I appreciate any advice and help!

Here a dancer's pad to float the first metatarsal head is made of Spenco material and glued to the bottom of the shoe insole. 1/8th inch to 1/4th is normal, but you should never feel like you are falling into the hole created.

Here the 1/8th inch adhesive felt from www.mooremedical.com is being used to change weight bearing off of the 5th metatarsal. 

Dr Blake's comment: You should do just fine with tap dancing with icing twice daily to reduce the inflammation, dancer's padding with 1/8th inch adhesive felt from www.mooremedical.com, use of Hapad Longitudinal Medial Arch Pads for the shoes from www.hapad.com. You may also need to learn to spica tape. 

Here Small Longitudinal Medial Arch Pads from the Hapad company are used as an arch support to transfer weight from the big toe joint into the arch and also into the 2nd and 3rd metatarsals and off the big toe joint. Because it is an adhesive felt, it can be moved around and thinned by peeling when needed. 

Always,

Inverted Orthotic Technique: Rx Writing Flow Chart

Components needed in filling out a prescription for the Inverted Orthotic Technique

When ordering the Inverted Orthotic Technique for patients with moderate to severe pronation, or those patients needing specific varus canting, this drawing above can give you the components to think about. The 4 basics aspects are:

1. Pouring Instructions
2. Positive Cast Instructions
3. Plastic Instructions
4. Additional Instructions

Future blog posts will look closer into each of these aspects. 

Varicose Vein Photo

Stretching: General Principles

Here are my 13 Stretching Tips for every muscle/tendon in the lower extremity (hips, knees, ankles, and feet). These general principles help to avoid injury and should be used daily. Proper stretching is vital to the health of our muscles.

•#1   Hold each stretch for 30(minimum) to 60 seconds, and repeat twice.

•#2    Alternate between sides while stretching (for example, right achilles with knee straight, then left achilles, then right, then left).

•#3    Do not bounce while stretching, hold steady.

•#4    Deep breathe to get oxygen into the muscles while stretching. Normally 5 deep breathes equals 30 seconds.

•#5    Stretching before exercise should be done after a light warm up, like walking or stationary bike or jog, and is crucial, and is crucial in preventing many injuries due to tightness like achilles or hamstring strains. Julie Cox, PT, recommends pre-activity stretching to be slightly less time (20 to 30 seconds) followed by gentle rhythmical motion to warm up the muscle group involved for another 30 seconds. For example, achilles stretching pre-workout could be followed by a gentle rhythmical motion for 30 seconds (back and forth) between raising the heel up off the ground and then lowering the heel back down. Stretching hard when the muscles are cold (based on weather or time of day) can injure the muscle and gives pre-workout stretching a bad name. I personally like 5 minutes of stationary bike or walking or a sport specific activity (shooting before a basketball game) before starting my pre-workout stretch.

•#6    Stretching after a work out is the most important time to gain flexibility since the muscles are heated up.

•#7    If one side of your body is tighter, do twice as many stretches on that side versus the looser side.

•#8    If you want to gain flexibility, stretch the desired muscle group three times per day, whether you work out or not.

•#9    If you want to maintain flexibility, average one time per day stretching the desired muscle group.

•#10  Never stretch through pain, it only makes the muscle tighter afterwards.

•#11  Make sure when stretching that your body is stable (not likely to fall over, etc)

•#12   Most muscle/tendons can be stretched for better results in various positions. For example, when stretching the hamstring, you need to stretch both the upper and lower parts. And especially for the lower hamstring, you can stretch various parts by positioning your foot straight, externally rotated, and then internally rotated. You will feel the pull on the hamstring at different parts.

•#13  With many muscle/tendon injuries, if you can find a way to stretch it which relaxes the sore area, you are going to heal much faster. As long as you can stretch without making it painful, you can stretch an injured muscle/tendon 5 to 10 times daily.

Positive Casts showing Forefoot Deformities needing different Orthotic Design

Podiatrists will start with a cast of the foot and some examination findings (both static and dynamic) to design complex foot inserts which change function and better patient's lives. It typically starts with an impression cast of the patient's foot. This image shows 3 left feet, all taken with the same cast technique, showing 3 different foot types. The cast on the right is fairly stable and neutral positioned. The middle cast shows a foot that easily rolls to the outside and needs stabilization for supination. This demonstrates forefoot valgus. The left side cast shows a foot that easily rolls inward producing over pronation. This is called forefoot varus, and there are various corrections for this based on degree of deformity. 

Forefoot Varus Orthotic Corrections: Based on Degrees of Deformity

Walk/Run Program for Injury Rehabilitation

The Walk/Run Program

Most sporting activities require some running. Running can be an excellent return to activity conditioner. After recovering from an injury, the athlete finds great physical and emotional strength from a gradual buildup of running. Injury rehabilitation can involve crutches, cast, surgery, and rest. At some point, when the athlete is back to walking 30 minutes, without pain, and without a limp, a Walk/Run program can be started.
The Walk/Run Program that I have used for many years uses a 30 minute time period, based after the more classic 30 minute hard walk test that qualifies the athlete to begin jogging. However, you can start the program based on a 20, 30, 40, or even 50 minute period. It all depends on what you want to get to. I have used the 30 minute program personally twice in my life, once after a back injury, and the other after a knee injury. I found the program difficult since I was out of shape for running, yet safe with its low start and gradual progression. It was not as easy as it looks when you have not run for awhile.

There are 10 levels:

• Level 1     Walk 9 min Run 1 min Repeat 3 times for 30 mins
• Level 2     Walk 8 min Run 2 min Repeat 3 times for 30 mins
• Level 3     Walk 7 min Run 3 min Repeat 3 times for 30 mins
• Level 4     Walk 6 min Run 4 min Repeat 3 times for 30 mins
• Level 5     Walk 5 min Run 5 min Repeat 3 times for 30 mins
• Level 6     Walk 4 min Run 6 min Repeat 3 times for 30 mins
• Level 7     Walk 3 min Run 7 min Repeat 3 times for 30 mins
• Level 8     Walk 2 min Run 8 min Repeat 3 times for 30 mins
• Level 9     Walk 1 min Run 9 min Repeat 3 times for 30 mins
• Level 10                    30 min Straight Running

Each level should be done 3 times minimum depending on how you feel. Each session should be followed by a rest day to see how you feel. Therefore, completing Level 1 should take a minimum of 6 days. For example, start Walk/Run on Monday, rest Tuesday, 2nd session Wednesday, rest Thursday, 3rd session Friday, rest Saturday, and ready to start Level 2 Sunday as long as Level 1 was fine.

Gradually work your way through all the 10 levels. Remember to stay pain free. If you pass to the next level, but your pain starts to come back, rest 3 days, and go back to the level you were comfortable at for 3 more sessions. Again try to get to the next level. If you again have troubles, stay for 6 sessions at the comfortable level continuing to run every other day. Most patients gradually go through the 10 levels in 2 months (60 days), but some have taken a lot longer to progress. Remember, if you listen to your body, not push through pain, you will make it very safely.

The Walk/Run Program works well with even minor injuries where there are questions of when to start running. If you have only been off running for a short time, but you feel anxious about starting running, try this program. In its quickest form, Level one first day, then a rest day, then level 2, then other rest day, and so on. As long as your symptoms are fine, and you do not push through pain, you can get through the 10 levels in 20 days. This is normally better than running 3 miles the first day, having a flare up of symptoms, then stopping running for 2 more weeks. It allows you to test the waters of running more safely.

Remember another Golden Rule of Foot: It is better to run 1 second than not at all. Patients ask me all the time if they can start running. If they can walk 30 minutes at a good pace, without pain, and without limping, then they can start running. Any running for most athletes is better than not running. If you can not do the 1 minute for Level 1 Walk/Run, try 10 to 30 seconds running telephone pole to telephone pole.

Getting back into running shape can be safe with a Walk/Run program. It may require some individualization, but you will go either at the speed you were meant to, or slightly slower. You will get there!! Good Luck.

Neural Flossing: Initial Lesson for patient with Ankle Nerve Pain

Podiatrists deal with a lot of nerve pain. Neural Flossing or Gliding is a great technique to be tried to gently move the nerve and prevent scar tissue and swelling to collect around the nerve. Here, this wonderful patient, agreed to have me video her initial exposure to Neural Flossing. The motion should be gentle and smooth. The patient should do 10 leg extensions and 10 leg flexions 3 times per day. For nerve pain in the foot and ankle, neutral spine is important. The patient should extend the hip, knee, and ankle with foot pointing, then immediately flex the ankle, knee, and hip. Comparing the two sides is a great way of seeing the differences, the starting point issues,  and the  progress made. This patient has a long way to go, but the lesson really showed us a lot of why she is still having problems with lower extremity stability.






http://www.drblakeshealingsole.com/2012/12/neural-flossing-gentle-stretch-to-break.html

Orthotic Modification: Easing the Transition from Plastic to Weight Bearing Surface

Post Sesamoid Removal Problems: Email Advice

Hi, Dr. Blake,

Your blog has been a WEALTH of knowledge for me this past year... I had a chronic foot injury that went undiagnosed (properly, at least) until March 2013. At that time, my expert ortho surgeon and I decided that my medial sesamoid would be removed, as it was fractured/fragmented. I also needed my bunion repaired and hammertoe (second toe) fused to allow a plantar plate tear to heal. The surgery took place in April 2013, and it is now Nov 2013.

 I have had MANY ups and downs since then. I've done everything I can to heal the right away--PT, acupuncture, swimming, orthotics, TENS machine, etc. I just had a follow-up visit last week, and I'm just disappointed with my progress... I seem to have "decent" and "bad" cycles of pain, and have been in a fairly bad one for the past few weeks. Prior to that, I thought I was turning a corner and started doing some more "challenging" activities like some light hikes in the woods and testing out some jumping activities, but always with orthotics on and atop thick Pilates mats! 
Dr Blake's comment: Flareups are very difficult to take during the 2 year rehabilitation course you are on, but you must get through them. Sounds like you are doing everything well. Do your orthotic devices protect the sesamoid area well? Develop a short Immobilization routine you do as soon as a flare strikes----typically removable boot and icing in some form. Remember, flareups are normal, normally not a sign of anything dangerous, and just means you misread what you thought you could do safely. I seem to be an expert at that scenario. 

I was doing great, I thought, but as of a couple of weeks ago, the remaining sesamoid region in the left foot started to bother me a bit. My ortho is quite positive it is NOT fractured--everything has healed VERY well on X-rays (screw in big toe is still in place and looks normal), but he said I could get a CT scan just to set my mind at ease... I'm not having a ton of swelling--I actually have not since surgery, but I DO have pain...
Dr Blake's comment: There is no indication of fracture, but the demineralization process from disuse can make the bones more sensitive. Motion of a still healing joint cause cause swelling in that joint. In the big toe joint, the swelling drapes over the sesamoids causing sesamoid pain when the sesamoids are fine. I hope these are part of your problem---fixed by walking, good diet, and icing/contrast bathing. 

 Part of my pain is related to my tendency to produce EXCESSIVE internal scar tissue when I've had a traumatic injury or surgery. When I fractured my right tibial plateau back in 1998, it took years to feel "normal" again, and I've had flare-ups. THIS is worse, though, as it's my forefoot and taking more pressure than even my knee! ;) At any rate, my ortho is very knowledgable about folks who are prone to excessive scarring (it's definitely genetic for me, though my scars LOOK fine externally!), but there's not much more he can do. My main fears right now are: 1) that I HAVE fractured the other sesamoid and 2) that I'll never feel less pain due to this excessive scarring... I really cannot bear it if I have to wear a CAM boot AGAIN for most of a year to see if yet another fracture will heal. I am praying it's just scarring/bruising/sesamoiditis, b/c at least I can "manage" that somehow... It's hard to know at this point what is "new" and what is just related to my body continuing to "rehab" from the surgery! I know I had rather extensive procedures done, but I guess I had hoped to be in a better place by nearly 8 months out. My doc said it could take my foot up to 2 years to calm down. Any suggestions at this point? Hoping to hear from him today re: ordering me a CT scan! I really don't want to have a totally sesamoid-less foot, but I can't really fathom going through my entire life worrying I've damaged the remaining little bone! ;) Help! Thanks in advance! 

Dr Blake's comment: First of all, you need to put yourself back in the Immobilization Phase with a Removable Boot with Accommodation, an EvenUp for the other side, and 3 times a day ice pack, until the symptoms of this flare calm down. For flareups, you really should be prepared to do this on a regular basis as soon as possible since it calms things down so much quicker. 
     Scar tissue maturation, when the external and internal scar thins out and gets in the way much less, always occurs from 9 months to a year. This will give you a better, less scarred, big toe joint, but will not even start until late Jan 2014 and end early May. You have over 2 months before that process begins, so I would be kind to your joint between now and May 2014. I would immobilize with flares, work on joint range of motion, work on foot strengthening, weight bear only with protection, increase your cardio (biking, swimming, etc) without jumping!!
     What has the PT said about your range of motion? How is your foot strength? How is your bone strength? You always get transient demineralization with casts making the other sesamoid and foot prone to stress fractures, so you must be getting your calcium and Vit D3 and know where you are at bone wise. 
     Get the CT scan and let me know what it says. Begin your own self mobilization as the video shows below. Have the PT measure you so we can have a starting point. This is very important if you are worried about internal scarring.