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Thursday, June 6, 2019

Medicare and Podiatry

Medicare and Podiatry how are you covered?
Podiatrists are doctors who specialize in conditions pertaining to feet and ankles. They can treat anything as simple as an ingrown toenail to plantar fasciitis. Aging adults are prone to chronic foot problems, especially if they have an underlying disease such as diabetes.
However, Medicare doesn’t cover all podiatry services. In fact, Medicare doesn’t cover routine foot care at all. For other podiatry services such as treating specific conditions and surgeries, Medicare has specific rules for coverage. First, let’s discuss what isn’t covered by Medicare.

Podiatry Services Not Covered by Medicare

Medicare doesn’t cover routine foot care except in situations where another health condition requires it, such as diabetic neuropathy. Routine foot card includes, but is not limited to, corn removals, debriding toenails, and maintenance care. Another condition that Medicare doesn’t cover any podiatry services for is flat foot.
Medicare also doesn’t cover supportive devices such as orthopedic shoes unless they are included in the price of a leg brace or the patient has diabetes. Medicare doesn’t cover these services because they are not considered medically necessary.

Podiatry Services That May be Covered by Medicare

Medicare will cover podiatry services that are considered needed to diagnose or treat a medical condition. Conditions such as hammer toes, heel spurs, and bunion deformities yield Medicare coverage for treatment.
Diabetes patients get a little more leeway when it comes to foot care because they have a greater risk of developing foot conditions. Therefore, if you have diabetes, you can receive a foot exam once every six months as long as you have been to a podiatrist for any other reason within those six months.
As we briefly mentioned above, Medicare will also cover services that are otherwise considered routine if you have an underlying disease. For instance, if you have peripheral vascular disease, a disease that reduces blood flow to your feet and other limbs, routine podiatry services may be covered. Other diseases and conditions that may validate routine foot care coverage are Buerger’s disease, peripheral neuropathies, and Arteriosclerosis obliterans.
Mycotic nails can be common in the aging community. Mycotic nails are nails that are yellow-brown in color, with a thick and brittle texture, and are usually infected with fungus. Medicare may cover treatment for mycotic nails if your doctor documents clinical evidence of infection, and you are showing symptoms such as pain or secondary infection.

How You’ll Pay for Your Podiatry Services Through Medicare

Podiatry services are usually performed in a doctor’s office in an outpatient setting. Medicare Part B covers medically necessary outpatient doctor services and therefore, will be in charge of your podiatry services.
Part B will pay 80 percent of your medical costs. You will be responsible for both an annual deductible of $185 and 20 percent of the bill. If you receive any treatments in a hospital as an outpatient, you will likely experience a copay as well.
If you ever require surgery to treat a foot condition and you are admitted in the hospital on an in-patient status, Part A will come in effect as well. You will have a $1,364 deductible for your hospital stay that will pay for your hospital services such as your room and meals.
This deductible will also cover your first 20 days in a skilled nursing facility (SNF) if your doctor recommends you finish your recovery there. Medicare will only cover your SNF stay if you were admitted to the hospital for at least 3 days.
When you apply for Medicare, you may want to consider supplemental coverage to help pay for things like this. Medicare plans such as Medigap and Medicare Advantage can help lower some of these costs. Medigap plans can help cover your Part A deductible and Part B deductible, copays, and coinsurance.
Medicare Advantage plans can help lower your out-of-pocket costs by setting a copayment amount that may be lower than your normal Part B coinsurance. Medicare Advantage plans also often offer extra podiatry services, such as routine foot care exams.
In summary, Medicare will cover podiatry services as long as they can be deemed medically necessary. If you’re unsure about whether your specific service will be covered, ask your podiatrist.

Monday, June 3, 2019

Big Toe Joint Pain: Diagnostic and Treatment Dilemma

Hi, Dr. Blake, 

I came across your blog and immediately felt the urge to ask you for your opinion on my foot condition. 

I am 38 years old woman and have been dealing with pain under the ball of the foot for a year. At first it was on the side of the ball which lead the orthopedist to think it was due to hallux valgus. 
But the joint was also swollen, so I did an MRI which showed a suspected "fracture" on the medial sesamoid bone, which could be a state after trauma.
Dr. Blake's comment: The one MRI view you sent me looked normal. What was the report? 
I got custom made orthotics (5 variations) and ate a box of Arcoxia, but after several weeks the pain was only worse. I do not have pain if I touch or press on the ball, but when I walk, the whole area is kind of sore. I walk on the outside of the foot, which I think makes it even worse - also the soft tissues around the ball are kind of stiff, I have to massage them. Some days it better, some its worse. 
Dr. Blake's comment: Start doing ice pack 10-15 minutes twice daily, and contrast bathing starting at one minute heat one minute ice for 20 minutes each evening. Non painful massage is wonderful 2-3 minutes and 2-3 times a day. Are the orthotics off weighting the area of the ball of the foot enough? 

I try not to walk a lot, since the condition gets worse after several minutes of walking. I can't do hiking or running anymore. I ride a bike, do Pilates (but no planks!), I also go swimming, but there is also pressure on the foot when swimming, so its not perfect. 
Dr. Blake's comment: this is great while you wait for healing to cross train. 

I made another MRI in January 2019: 
"In the distal part of the medial sesamoid bone transverse is a moderate hyperintense line. The bone structure of the distal pole of the sublingual bone is somewhat non-homogeneous, somewhere hyperintensive ________ (there is a word missing in a report). The proximal part of the sesamoid bone has normal signals also on the contact surface. It could be a bipartite sesamoide bone with degenerative 
changes in the distal core, less likely for a condition after an old injury."

Dr. Blake's comment: Try to send more images. You can send 8-9 that shows sesamoid bones for the 3 MRI directions.

The doctor said that MRI is not very clear, and it clinically looks like sesamoiditis, but that it's strange that it doesn't hurt when he presses on the area. He suggested PRP (platelet rich plasma).  Do you have any experience with it curing sesamoiditis?
Dr. Blake's comment: No, has promise for tendons and fascia. You do not know what is wrong yet. It would be very experimental and guess work at this point. 

I also tried taping the foot which helps a bit, physiotherapist did a laser, which kind of helped, but he said it's no use coming back, since it will be always be worse when I walk again. He suggested MBT shoes. 
Dr. Blake's comment: Start doing the normal stuff for sesamoids right now: Hoka Shoes with the rocker, cluffy wedges, dancer's padding, some arch support, spica taping. Do them all and limit walking this month June to day to day what you have to so. Work on the inflammation with ice, contrasts, arnica lotion. See if you can not turn this around. 

I visited 3 doctors and one of them said there's nothing you can do besides custom orthotics and 2 of them (which were private) said, they would try with PRP. A trauma doctor gave me a cortisone injection which didn't help at all. 
Dr. Blake's comment: stay away from cortisone if we do not know what is wrong yet. What lead up to this pain developing? Were you walking too much? Did you bang it? Are you a terrible pronator? 

I am very confused since I don't even know what is wrong and I am reading all about the different diagnosis over the web and different treatments, but my doctors don't seem to know anything about this possibilities. I was never offered a walking boot or suggested a period of immobilization. I asked about the option of doing some additional research, but he said he could do a scintiography, but it would only show if there is any inflammation, but would not show the cause. 
Dr. Blake's comment: I actually think the scinitiography would be great to see if the bone lights up. Definitely, walking in a removable boot (you can purchase the Anklizer type) at least to help you do more walking every day would be great. You have to place dancer's pads some times. Even if you wore only for the 4 hours per day that you are on your feet that would be helpful. If you feel off balance, get an Even Up for the other shoe. 

I'm also reading about contrast baths, HBO program, shock treatment therapy, Exogen bone stimulator (which I mentioned to my orthopedist, but he said, "you can't stimulate if there is nothing broken ...")
 ... but I am no doctor and I really don't know if any of these treatments would be good for me.  Non of the doctors I have visited haven't advised me anything of it. Custom orthotics, PRP and finally operation if all fails, that is all.
Dr. Blake's comment: Contrast bathes, usually one minute hot and one minute cold for 20 minutes in the evening is good to reduce swelling, while ice just controls it. 

Can you give me some advise? What is my problem, fracture, degeneration ...fragmentation ...?
Could I have AVN?
Dr. Blake's comment: need more images for sure. In general, when the sesamoid is injured, it is really sore on light palpation, so we have to make sure you even have a sesamoid injury in the first place. 

A big thank you in advance, I can't wait to read your opinion.

And when I did not answer (as I am taking a lot of vacations this year):

Hi, dr. Blake, 

I was just wondering if you got my email? I really could use an advice from someone experienced as you in this area. 
Since the condition hasn't got any better, I received a PRP injection last week. I asked the doctor about non-weight bearing and if I should use a walking boot and he said there is no need to. I am so confused, because I read on your blog that all other patient are supposed to not bare weight during a period of time. 
Dr. Blake's comment: The goal is to do what you can to control the pain to 0-2 levels. Typically, only really acute injuries need non weight bearing. Normally, I love the removable boots, anti-inflammatory measures, and activity modification to protect the area while the diagnosis is being made. 

After 6 days the area is swollen and sore, yesterday I even stepped a bit too hard on that area and experienced sharp pain (I am trying to not step on it at all, having custom made orthotics and dancers pads  and walking on the outside of the foot) and now it even more sore. 
Dr. Blake's comment: Non weight bearing typically makes the swelling worse, so protected weight bearing is better with the boot. Any step you take pushes fluid out of the foot. Occasional sharp pains are okay, as long as they only hurt temporarily. 
Do I ice it or do contrast baths or not? I am supposed to have another shot in a week, but I am not really sure if I should do it, since there is no improvement yet. 
Dr. Blake's comment: See above comments on ice and contrasts, get the boot ($60 on amazon), get the scintiography if you can, send me more images. Do non painful massage several times a day. Send me a photo of the top and bottom of both feet now. 

I would be very happy for your opinion.
Thank you

Saturday, June 1, 2019

Chronic Metatarsal Pain: Email Advice

hello dr Blake,
I am writing all the way from Italy and was wondering whether you could be so kind as to help shed some light on a foot problem I've been struggling with for the past 5 years. I hope you enjoy puzzles! I'm 33 years old, male, 6' 4'', 165 pounds. 

5 years ago I suffered a minor injury which caused capsulitis on my 1st MTP joint (right foot). Eventually the capsulitis resolved, but at the same time I gradually started to experience additional discomfort on the same foot for reasons which in hindsight seem to be attributable to increased weight/pressure on the affected foot when walking. For example, the metatarsal pad of the orthotics I had been prescribed to treat the capsulitis after a few months started to be painful (whereas with my left foot I could barely feel it), and after I switched to a pair without the met pads (April 2016), the discomfort shifted to other areas of my forefoot (sometimes lateral, sometimes medial, and always when pushing off). Sometimes I had the unpleasant sensation of 'feeling' my metatarsals when walking. Fed up with the orthotics, I tried to go back to walking without them as I had always done for 30 years. After a few days of walking pain-free I thought the condition had finally resolved and everything was back to normal, but shortly after the old symptoms came back. 
     So I went to see a podiatrist (January 2018), who said that my discomfort was due to unilateral over pronation and that I needed semi-rigid orthotics. The new orthotics worked very well for a couple of days, but then again symptoms-wise I was back to square one, with modest improvement. The podiatrist then made me a rigid pair of orthotics, but again, very little changed. Since he couldn't see any structural faults he came to the conclusion that the problem was muscle-related, more specifically my right calf was weak. This was maybe due to the original injury, since the capsulitis made it painful to push off as usual and so probably I started to use my calf muscles less and less. Nowadays I can rise on my toes on a single leg but I find it much easier with the other limb. I signed up at the gym, carried out a 4-month program with a fitness instructor (nothing specific for my problem though), experienced some improvements but very discontinuous, and finally went to see a physiotherapist (March 2019).
     The PT noticed a number of compensation patterns on the affected side, mainly internal rotation of the leg, pelvic tilt, an overactive tibialis anterior, and something about my latissimus dorsi which on that side was working harder than normal to maintain balance. I did 5 sessions where they manipulated mainly my pelvis and trunk, the reasoning was that all of those imbalances were affecting my foot, and not vice versa. On some days I noticed a definite improvement, but again, a bit discontinuous, so eventually they referred me to a podiatrist they knew in order to rule out intrinsic foot problems (April 2019, i.e. this week). 
Dr. Blake's comment: First of all, I am sorry I am late answering. You are not overweight and I am not sure that their is any association with the original capsulitis. All of your symptoms could be related to your unilateral pronation. If you look at your two orthotics, are they asymmetrical, with more support to the unilateral pronation side. 
     The podiatrist noticed a number of things apart from the unilateral over
pronation (ligamentous laxity, not much forefoot fat pad, big toe tends to make little contact), but the main thing seemed to be that the affected leg is 0.4" longer).  Thus, I would need a new pair of orthotics that took all of these things into account. I have no qualms about that, and I am willing to believe that 0.4" could go a long way to adding weight on my leg and foot and contributing to the problem. The affected leg is probably a bit longer, my fitness instructor once filmed me while walking on a treadmill and it clearly showed that the affected leg tended to circumduct (is that a verb?), and the anatomical leg length discrepancy may be compounded by a functional one.
Dr. Blake's comment: Yes, the long leg tends to be the more pronated, and 11 mm is a lot. I tend to try to separate the orthotic therapy and the lift therapy. So, I would gradually over one month build you up under the short side. When the patient is more pronated on the long side, correcting that aspect will make that side even higher, so you may need up to 1/2 inch. 

     I am willing to accept all of this. What I really can't wrap my mind around (and this is my main question) is this: if it really is a matter of bearing too much weight on the affected foot then why did it become symptomatic only in recent years, after the original injury? If the leg length discrepancy is truly anatomical, shouldn't I have had similar problems before the injury as well? The injury itself was no big deal, I hit a curb with my big toe but no fractures, just the capsulitis. Until 5 years ago I had never had the slightest problem. Could compensatory postural adjustments or lower leg muscle weakening post-injury have played a role in adding further weight to the affected side?
Dr. Blake's comment: Yes, for sure, an injury can cause other stresses to manifest for the first time. I am never sure if it is due to the deconditioning from the injury, or the compensations from the injury, but it happens all the time. I joke to my patients that at least it will stop after the third area begins to hurt (sometimes they get my humor). The long leg does put more stress on that foot for sure, and if you add the tightness that develops in the achilles with injuries, the stress to the injured foot can be quite bad. 

I'm adding a few bits of info which might help:
  • I tend to feel much less discomfort when walking barefoot (Dr. Blake's comment: for sure, shoes for sure add stress across the metatarsals as we try to bend at push off. Only stress fractures and other bruises hurt worse barefoot. This of course could be a clue for you to try very flexible shoes in the forefoot)
  • x-rays and MRI have always come out 'clean' (Dr. Blake's comment: Negative MRIs to me mean nerve injury first until ruled out. Nerve injuries show negative MRIs. Have you had any nerve symptoms like numbness, sharp, tingling, buzzing, electric, etc. It is also a good sign for the future as you do not have early onset arthritis).
  • pedograph analysis showed more pressure on the affected foot when walking, thought barefoot they were even (Dr. Blake's comment: Many times the difference only shows up running as are bodies have a harder time distributing the weight evenly.)
  • I tend to think that I am bearing more weight on the affected foot, but there are no signs of that on my skin (there is a slight degree of 'hallux valgus' though, could that be a sign?) Dr. Blake's comment: Yes, unilateral bunion formation or hammertoe formation is a sign of more stress.
  • as I mentioned before the discomfort I have on my forefoot is quite changeable, most times it's on the head of my 5th metatarsal, sometimes it's bit generalized, other times I don't feel anything on the 5th metatarsal and it's more on the big toe. In any case, it's always during push off. Dr. Blake's comment: The variability is more a stress syndrome than an injury. Change the mechanics, get stronger with single leg balancing and metatarsal doming, and stretch the achilles tendons several times a day. 
  • judging from what I see and from the pedograph analysis the arch of the foot seems fairly normal
I would be really grateful if you could share some thoughts on all of this, I've been through so much and am getting a bit depressed

thank you
Dr. Blake's comment: I hope you are feeling better. Get more flexible, get stronger, get at least 1/4 inch full length lifts and see if you are better with these changes. Rich 

The patient then answered:

hello dr Blake,
thank you very much for answering. I am writing a follow-up email to let you know how I am doing. If you feel to add any ideas or suggestions that I could pass on to the professionals that are looking after me (also in terms of diagnostic tests) I would be even more thankful (I have made a small donation to your blog as a token of gratitude). I don't want to take advantage of your kindness so if I don't receive further communications I will fully understand.
Over the last month and a half I have been wearing the new pair of orthotics (they have a 5 mm heel lift on the shorter leg, so the lift is not full length), my gait has improved as now I find it easier to push-off (last pair of orthotics were rigid and with little padding), while symptoms have also improved a bit but have not resolved. I am still doing physical therapy and next Wednesday I have a check-up with my podiatrist so I hope to clear things up a bit, but in the meantime I have been doing some research on a number of topics and I have come up with some new elements that may be worth mentioning. As my foot is apparently subjected to increased stress, I'm trying to understand what is causing it.
Dr. Blake's comment: Explain to the podiatrist to perhaps experiment with another orthotic device for the short side without the lift attached and with 2 (1/8th inch) full length spenco or other soft material as lifts one full length and one cut at the toes (sulcus length). That will add cushion but not pitch you forward as much onto the metatarsals. If you use soft material as lifts, you typically can go up a mm or 2 due to the compression. 
One of the working hypotheses is that it may be bearing more weight for some reason, but I've noticed this is something that hardly ever pops up in podiatry or PT. I have read several textbooks and at the most they talk about asymmetrical weight distribution foot-wise (i.e. more lateral or medial) and not body-wise (i.e. right leg/left leg).
Dr. Blake's comment: One method of getting some idea of the right to left weight bearing is looking at old inserts, ones that you have worn awhile, to see if one side is broken down more. The other common method is to stand evenly on two bathroom scales that you know are equally calibrated. Try to stand with equal weight in your mind, and have someone else take the measurements of left and right side. As soon as you look down to read the scales, you throw off this technique. It is only one tool, other than more sophisticated force plates/mats, but seems to be helpful. 
 I am wondering whether muscular imbalances in terms of tightness/weakness between the two halves of the body might play a role in how weight is distributed or force is transmitted to the lower extremities but I haven't been able to find any bibliography on the matter. Also studies on LLD and body weight distribution seem conflicting as to which leg bears more weight, so it's all a bit confusing to me. I did another pedobarographic analysis last month which apparently ruled out this asymmetrical weight-bearing hypothesis, as it showed that mean pressure was actually higher on the healthy foot when walking barefoot, but I don't know if such a test is supposed to be conclusive on this matter.
Dr. Blake's comment: I am not aware of any research on this matter, so I apologize. When a patient is bearing more weight on one side because of short leg syndrome, scoliosis, tight hamstrings or calves, weak muscles, etc they create postural instability as they try to compensate. This postural instability can lead to the measurements varying from step to step, with one side greater with one step, and the other side greater with the next step. Or, something like this. The force plate analysis as an office tool makes it difficult unless you do the test multiple times, and a definite pattern emerges. Most researchers feel you must walk over the force plate 10 or more times even to begin to practice the landing. This is actually why in a busy office I have not purchased these, but I understand their help in many situations. 

You mentioned in your reply to check for neurological signs, and this is something I didn't include in my first email. I do think there is something going on in that regard as well. One sign involves the dorsal aspect of the big toe, so I don't know if it's related to the general problem (forefoot plantar discomfort) but nonetheless it's worth mentioning. Sometimes I feel a mild burning sensation coursing along the big toe which is (sometimes, not every time) elicited if I move my leg after a period of inactivity when seated or lying down, and on sitting down after a walk.
Dr. Blake's comment: This is classic L4 nerve root irritation.

Or, also, when I'm doing sit-ups with my leg fully extended. What makes me think it's neurological is the fact that this burning sensation is sometimes elicited by stimulating the anal area (e.g. when I wipe after going to the bathroom), a very distant area that is directly connected to the foot only by means of nerves. I know that the deep peroneal nerve innervates the first web space and that it can get irritated when sitting with your legs crossed (something I used to do), but that doesn't match 100% my symptom in terms of location, as it's more dorsal 1st toe rather than 1st web space, and the peroneal/sciatic nerve is more 'buttock' than 'anus'. This burning sensation started post-injury, and I definitely remember that a few years ago sometimes I felt it coursing down my medial calf, on the side. Might it be that some nerve got irritated/damaged with the injury (big toe stubbed against a sidewalk) or consequent capsulitis? I know also that overpronation can cause tarsal tunnel syndrome but in that case symptoms involve the arch/ankle (not my case).
Dr. Blake's comment: This is up to a neurologist to put together, but sounds very neurological. The dorsal of the foot is irritated by tying your shoes too tight or above the knee problem like tight hamstrings, piriformis, or low back, not the tarsal tunnel. 
On the other hand though it's puzzling because other than the burning feeling I've never experienced the classic neurological telltale signs, i.e. tingling/numbness/electrical sensation, and it's something which is elicited with specific motions, and never at rest or at night.

All of this dorsal-big-toe-burning-symptom, though, as I said may not have much to do with the general problem, but I have come to think that there might a neurological component in the plantar aspect as well. Might it be that some plantar nerves are being compressed/being put under stress for some reason, and that weight-bearing pressure is 'felt' much more than usual? On the other hand, as I said before, the telltale signs of neuropathy are absent, and even on forceful palpation the sensitivity of my foot appears normal, so to my layman eyes it appears more a matter of stressed soft tissue than nerves.
Dr. Blake's comment: You have some minor nerve problem, and nerve problems cause a hyper-sensitivity that can make something hurt more at the foot. This is called "Double Crush". Definitely worth to check out, and right now deal with them separately. I hope I have helped and thank you for the donation. Rich

Again, thank you very much for your reply and for any further help you can provide


Wednesday, May 8, 2019

Typical Athletic Rehabilitation Course

     This graph, which could mean anything, reminds me of the typical rehabilitation course I help guide my patients on. Initially we try some things, some work and some don't, but we get smarter during this time. There could even be a slight increase in pain. Yet, as the rehabilitation goes, with typical components in place the patient starts getting better. These components include:
  • activity modification
  • anti-inflammatory
  • immobilization (boots, braces, taping)
  • orthotic devices
  • stretching
  • strengthening
  • shoe gear changes
  • technique changes
  • cross training
Then, as the patient and I feel they are ready to run, or starting back dancing barefoot, etc, the pain can reflare and we have a slight setback. All and all, at the end of the 3-5 months for a typical injury, the full return to activity is accomplished. I think the dips in the graph above, when the pain increases, is important to know that is it normal part of the rehabilitation process. Rich

Tuesday, May 7, 2019

Balanced Healthy Program for Life

     This image reminds me how poorly I exercise. Being in sports medicine my whole life, you would think I was better. But, I have my weaknesses, and one is spending too much time on activities which will strengthen my legs, and not enough on other parts needed to be healthy. We can all create even better lists, but here is my stab at the perfect health program checklist. The components are:
  • Healthy Diet
  • Good Hydration
  • Proper Sleep
  • General Health (including checkups, dental hygiene, scheduled tests)
  • Leg Strength
  • Balancing (called Proprioceptive)
  • Abdominal or Core Work
  • Upper Body Strength
  • Flexibility Work
  • Standing Strength Poses (Yoga, Tai Chi, Chi Gong)
  • Cardio
  • Proper Recovery Time
  • Great Mental Attitude towards Injury Free Activities
I am quite sure I have left out a few areas on the tip of my tongue (sort of speak).

Stem Cells, PRP, Amniotic Membrane: Good Website Discussion

     I just saw a young gal with a bad arthritic ankle. She has had stem cells injected with long more pain, but it may be the arthritis itself. I found this website for real patients to discuss their concerns or results. After reading all of this, you want the doctor who performs these procedures, to be something they do all the time, like I am a rehabilitation specialist, they should be regenerative specialists.

Sunday, May 5, 2019

Decision Making in Medicine

     In Medicine there are many decisions to make. The orange arrow above represents the most straight forward direct treatment that you will normally have recommended and that will normally greatly improve your situation. But there are normally other decision avenues that make sense to explore, especially if the typical course is surgical or invasive some way. 

     One typical example concerns bunions. Those are those big bumps on your big toes that can exclude your entire shoe closet.  The typical course is surgical correction (orange arrow). The purple course starts with all the conservative treatments and can go on for years: toe separators, wide shoes, Yoga Toes, Correct Toes, icing, padding, etc. The purple course is standard, and not really thinking outside of the box. The green and red courses are clearly deviations from normal. The green, left brain, is logical, and just means you avoid all shoes that irritate the bunions. The red, right brained, is artistic, definitely thinking outside the box, so may involve acupuncture, laser therapy, homeopathy, special massages, special solutions for soaking, etc. Are any of these 4 directions wrong? Any doctor will have their opinion. I think in general we must do no harm. The goal is the easiest solution to the problem which minimizes or eliminates the disability present. 

Saturday, May 4, 2019

Supinators: Adidas NMD R1 Shoes to the rescue

I love this shoe for my supinators. I comes in various colors also. The image above shows the support along the lateral side of the foot which is very special and unique in the shoe industry. 

The Health Care Provider's Emotional Health

Jack Ma, the former CEO of Alibaba, recently made the press over his support of work days from 9 am to 9 pm and 6 days a week. This is so strongly criticized in the press calling this 996 mentality terrible for the workers. I had to sit down with myself and realize I am normally 776+ (7 am to 7 pm 6 days a week) to get my work done, the plus being some work that can remain to do on Sundays. Medical school in most instances selects very hard workers in college that can obtain good grades in a pre-med environment. That work ethic or obsession or drive gets you through the next decade of medical school, internship, residency and starting a practice. It is the doctor's basic personality which greatly rewards the doctor financially and emotionally. But, over the years, that work ethic can beat you down. The burn out rate of doctors is extremely high today. The demands in my mind seem less related to patient care and more related to paperwork and other expectations. Before the business takeover of medicine which started over 30 years ago, and has only gotten worse, my practice of medicine was 80% patient care, 10% research, and 10% paperwork (865+). Now my practice of medicine is 50% patient care, 50% paperwork (or computer work), and research or blogging is left the time I really should be relaxing. I have no solution, but the next time you see your doctor, give them a little hug if you are inclined (we hug in San Francisco). 

Friday, May 3, 2019

Putting the Pieces of the Injury Puzzle Together

My practice of medicine has much to do with trying to put pieces together of a puzzle. The puzzle being why an injury or pain syndrome occurred, or how to fashion a successful rehabilitation program for a patient. The image below can also stand for all the members of a team gathered to help a patient.

When a patient presents with pain, the Rule of 3 holds reign in establishing why something happened. The Rule of 3, and commonly 4 or 5, stand for the factors that had to exist for a problem to develop, a sort of perfect storm. One simple example is from a patient I saw yesterday. The patient has a tibial stress fracture from running. The injury occurred in clear overuse fashion (Cause #1). The injury, which is to a bone, occurred during a time of low Vitamin D (Cause #2). The runner is a overpronator who had recently prior to the injury switched from Stability shoes to barefoot technology shoes which proper transitioning period or running style changes (probably Causes #3, #4, and #5). By putting these pieces of the puzzle together, the patient was be successfully rehabbed, and the injury will not reoccur. 

Spider Veins from Dr. Jodi Schoenhaus

I thought this was an appropriate presentation to address these cosmetic issues. One of the biggest points Dr. Schoenhaus makes is to make sure these lesions are not the sign of a more serious problem in the veins first and foremost. Rich

Thursday, May 2, 2019

Sesamoid Pain and Cleats for grass sports

There have been quite a few times when an athletic whose sport requires cleats that the sore sesamoid under the ball of the foot is right over one cleat. It is great if you can shave down the cleat in that spot as long as stability is protected by another cleat. 

Wednesday, May 1, 2019

Music and Athletic Performance

I have found listening to upbeat music over a book on tape greatly helps my athletic performance. I am glad that there is some proof to it’s effects. Rich

Single Leg Balancing vs Dancer's Pose

Hi Rich .... I took a pole-hiking class - loved it! But the teacher said two-minute balances were bad for the hips.  It throws them off or out.  She says instead to do "Dancer" pose in yoga - it's more dynamic and engages the glutes. (I don't remember all she said) But she was adamant about it.
Since my hips have been hurting --- have you heard this before? Do you recommend it?

Hey, thanks for the email. I love single leg balancing as you strengthens the foot to core. Yes, it you are doing it at a time that something hurts, you may have to reduce the time. But, single leg balancing is so natural for the body as it simulates actually what is happening in the middle of each step with our body perfectly stacked up or aligned. Below is the video I did on balancing and one I found on you tube on the Dancer's Pose. The stress to your hips doing the Dancer's Pose seems so much greater than a Single Leg Balance exercise. And, for my non yoga patients, the time to build up to be good at a dancer's pose seems so much longer than single leg balancing. But, please get me more feedback. Thanks Rich

Monday, April 29, 2019

Bone Injury Problem: Email Advice

Dr. Blake,

I saw your blog and was very impressed with your ability to break down
foot issues in a way a layperson can understand. I’m writing to seek
advice about my current situation.

I recently had an injury caused by running. In December, I ran on
mostly concrete a handful of times with trail runners (New Balance MT
10v1), since I was visiting family and did not bring my normal running
shoes. This was a big mistake. At the end of the month I started
feeling a severe pain in my left foot. For 2 weeks I was minimizing my
walking, and mostly limping around. After 2-3 weeks my left foot felt
better, but I had a lingering pain when applying pressure just below
my big toe, to the right on the side of the foot. I did not feel this
while walking, my foot/toes had full range of motion, and otherwise
would not notice unless I put pressure on that spot specifically.

I went to my general physician 6 weeks after the original injury, and
he recommended seeing a podiatrist if it didn’t get better within 2-3
weeks, since it didn’t appear that I had broken any bones. I saw a
podiatrist soon after, and after an X-ray showed there were no broken
bones they determined it was sesamoiditis. They recommended I wear
dancers’ pads for some time, and to come back if the discomfort did
not subside in 3 weeks. I went back, and got an MRI that time. Not
only did I have sesamoiditis, but I had a stress fracture in the 3rd
metatarsal bone along with the bone behind it. There was evidence of a
previous stress fracture as well, one that only partially recovered. I
was given a CAM/walking boot to wear for at least 4 weeks, and they
were to provide custom orthotic inserts to put in my shoes after. In
both visits my podiatrist also noted I have very flat feet, and that
treatment afterwards will need to keep this in mind. I am now entering
my third week wearing the CAM boot, and have started planning ahead
for my recovery once I'm out of the boot.

Before my injury I have been a regular weightlifter for 7 years, and I
never had any injuries related to that. However, I have done very
little cardiovascular exercise, practically never running before late
last year. Despite that, I walked a lot, often averaging 8-10 miles a
day on weekends. I would wear various types of shoes, ranging from
ordinary sneakers, athletic shoes similar to the Adidas Ultra boost,
and minimalist boots (Vivobarefoot Gobi II). Even though the
minimalist boots had nearly no support, I found walking with them
quite comfortable even for long distances. I find either minimalist
shoes (due to the wideness at the front, giving my toes a lot of
space) or Ultra boosts the most comfortable for long distances.
Ordinary sneakers generally felt a bit tight after a while.

After this injury though, I am re-evaluating what footwear is best for
me. Since my shoe selection may have been a cause of my injury, I want
to ensure I don't make the same mistakes.

In my anecdotal experience, walking in minimalist footwear was fine,
but running was definitely not. Is this a result of the surface I ran
on with minimalist shoes?
Dr. Blake's comment: First of all, I am sorry it has taken me weeks to answer your question, for I was
on a great vacation and three weeks later still not caught up. It is all about accumulative stresses to our bones and soft tissues. I always look at 3 causes of an overuse injury, and the most common ones at that, since it is never one thing. In your case, what could possibly stress out the bones enough to cause sesamoiditis and stress fractures. The most common in order are:

  1. Increased running without enough recovery time (typically 48 hours if you do not have a good running base).
  2. Less bone protection with more minimalist shoes, especially when you were not used to them, while running.
  3. Overall bio mechanics of your running form (no info here)
  4. Overall bone health (could there be Vitamin D Deficiency) since you are picking on bones that need Calcium and Vitamin D among other things
  5. Type of training (hills and speed work harder on the sesamoids), downhill with a tremendous increase in bone stress (up 3 times flat ground running)

It’s almost certain my running form could
use some work as an inexperienced runner. As someone with a flat foot,
is it possible to walk with more minimalist footwear but run in well
supported shoes?
Dr. Blake's comment: Yes, so many of my runners only wear more protection for their running, and some just for their longer distances, and the minimalist shoes for speed work and walking of course. 
Or should I wear shoes with a lot of support
regardless of whether I am running or walking?
Dr. Blake's comment: No need unless your biomechanics is so bad you need both orthotic support and shoe support all the time. That is rare. I like to patients to have variety in shoes, orthotics, training. I also need my runners to have good bone health, and to be strong from foot to their cores. I hope this helps you some.
 I have seen conflicting
information online and would love your thoughts on this.


Hip and Shoulder Pain: May be Related

     This little schematic is a good reminder to me of how the body works sometimes. The hips and shoulders tend to work opposite (and affect each other opposite) like when the left shoulder hurts that can cause the right hip to hurt. When you swing the right hand forward (connected to the shoulder) it is the same time as the left hip and leg are going forward. Equal and opposite. This is normal mechanics with one affecting the other. Tightness in the left shoulder can cause tightness and pain to start developing in the right hip and low back. 
     When the symptoms always appear on the same side, say right hip and right shoulder, as a podiatrist I am looking at structural or functional leg length differences. 

Sunday, April 28, 2019

Foot Massage: More Than Just Feeling Good

     I wish all my patients could get a good foot massage on a regular basis, but even their significant others do not seem motivated. I am sure it is in the delivery, since I have never had one myself. But, countless of patients with Morton’s neuromas, general foot pain, or post sprains have told me time and time again how important it is. Loosening up a tight restricted foot, as long as the pain level is respected, can only help as our feet slowly tighten up over time

Saturday, April 27, 2019

Causes of Pain: Mechanical, Inflammatory, and Neurological

My son, wife, and grandson all had lunch today in Paris and went up the Eiffel Tower. I wish them a safe trip home.

     I need your help. I want to use this blog as a way to help mankind. Being a Podiatrist, a foot blog seems appropriate and so I have had 9 good years trying to help. Since my work has required so much of me, my blog suffers as my hour each day as turned to 15 minutes, and usually directly to the patient and not on the blog itself. Please help by letting me know what you want me to write about. After 9 years, I have really only scratched the surface. 
     When you have an injury, especially if it is over 6 months, you must treat the 3 causes of pain since all will probably be present. Mechanically at least try to shift weight a-little. I just wrote a post of 28 ways of changing the mechanics that can help big toe joint pain. Every injury has mechanical changes that can help. Treat the inflammation in the tissues with ice, contrast bathes, and other methods like lotions. And treat neurological pain, possibly due to nerve hypersensitivity that loves to  protect the tissue, with neural flossing, topicals for nerve like Neuro Eze, warmth, etc. I hope this helps and any help you can give me is appreciated. 

Thursday, April 18, 2019

Good videos for Shin Splints  This is a good video, but I personally do not like the stair exercise.  This is my video and just look at the beginning which shows the anterior tibial strengthening.

Tuesday, April 16, 2019

Big Toe Joint Pain: Spica Taping can Help!!

 Spica taping is a technique with several variations that primarily limits the bend, or dorsiflexion, of the big toe joint. One of the variations is to help the same tape align the hallux that is drifting lateral causing lateral impingement. Spica taping is commonly learned with KT tape or RockTape since it goes around the bends of the toe fairly easy. If the patient needs more restriction, and has the basic skill down, then 3M Nexcare Waterproof Tape is used. This is a skill I want my patients to learn and perfect. It is part of my initial experimentation into what helps eliminate the joint pain. Typically one inch wide tape 7 to 8 inches long is centered dorsally over the top of the hallux. First the medial leg is brought down under the big toe joint and then run under the first metatarsal. Second the lateral leg is brought down under the big toe joint, and then run parallel to the first strip along the orientation of the first metatarsal. At least one half of the lateral leg should be touching the skin so that the tape can last 3-4 days. Make sure with KT or RockTape that you then rub in the finished product for a minute to activate the glue. The big toe itself when you are finished should be just slightly below the 2nd toe. Spica taping is classic for hallux rigidus and turf toe, but can hold the toe down with sesamoid injuries distributing the weight bearing somewhat away from the sesamoid. Spica taping can increase the compressive forces across the joint, which may hurt, so you just have to try to see if it makes sense. Below are 2 videos I did.

Sunday, April 14, 2019

The Complex Biomechanics of the Big Toe Joint

I have recently had a wonderful vacation with my wife in Hawaii. During that time, I was working each day on a book on biomechanics for podiatrists. I will share here something that took 5 days to write just on the complexity of the big toe. It is meant to tell you that if you have big toe joint pain, or you are treating a patient with big toe joint pain, there are so many options mechanically to help as you work on the inflammation and nerve hypersensitivity, and making an accurate diagnosis. The book will be several years in the making, and I am still looking for a publisher. I hope it shows you the possibilities available. Most of the modalities listed can be found in the blog.

Coastline near Poipu Beach on the island of Kauai

  First Metatarsal Phalangeal (Big Toe) Joint Mechanical Challenges

by Richard L Blake, DPM

    The big toe joint is a fascinating area to try to help because of all the variables that come into play. Since the end of normal stance in the gait cycle ends up with us pushing off the hallux with first metatarsal plantar flexion, and our goal in treatment is not to have the patient limp or favor in any way which would negatively affect the entire chain above and lead to other problems, we have a difficult assignment. I tell my patients with chronic big toe joint pain, from sesamoid issues, to hallux rigidus, to chronic turf toe, that they made need multiple orthotic devices and a variety of other helpful modifications and accessories. I thought this would easily be the area the inverted  orthotic device would work for, and it does for some, but the higher the arch you make (in order to transfer weight to the arch and shift the weight to the center of the foot in propulsion) the more plantarflexed the first metatarsal becomes. The more plantarflexed the first metatarsal, the more chance the big toe joint will be forced down into the ground worsening the pain. Therefore, where the Inverted Technique or even an orthotic made expertly for a pes cavus foot type made work some of the time, some of the time they do not and you have to make a flatter arched orthotic device or no orthotic device at all. Below we will talk about each one of these mechanical changes.

    The four big issues involving the first metatarsal phalangeal joint are:
  1. Bunions
  2. Hallux Limitus/Rigidus
  3. Sesamoid Injuries
  4. Turf Toe Syndrome
Each of these problems, and other problems involving the big toe joint, will have certain mechanical changes that help. I hope the list below helps you think outside your normal routine in creating a stable joint and getting the pain levels quickly to that 0-2 healing environment. I commonly think of pain in the big toe joint coming from excessive ground pressure, too much bend, malalignment with valgus forces, superficial pressure from shoe gear, or compression forces across the joint. To affect many of these causes, you have to do treatments that affect the patient in the propulsive phase of gait.Think of these as you work through the 32 common  mechanical changes done to the big toe joint.

Common Mechanical Changes at the First Metatarsal Phalangeal Joint
  1. Spica Taping
  2. Bunion Taping
  3. Toe Separators
  4. Dancer’s Padding
  5. Cluffy wedges
  6. Morton’s extensions
  7. Orthotic Devices for Weight Shift with no extrinsic post
  8. Orthotic Devices of Stability only with no extrinsic post
  9. No Heel Lift
  10. Zero Drop Shoes
  11. Rocker Shoes
  12. Bike Shoes with Embedded Cleats
  13. Cam Walkers or Removable Boots
  14. Stiff Shoes (including post operative shoes)
  15. Flexible Shoes
  16. Forefoot Padding
  17. Skip Lacing
  18. Deep Toe Box
  19. Wide Toe Box
  20. Shoe Stretching
  21. Carbon Plate Full
  22. Carbon Plate Morton’s Extension
  23. Carbon Plate Dancer’s Modification
  24. Proximal Padding Dorsal or Medial
  25. Metatarsal Padding sub 2nd through 4th or 5th
  26. Self Mobilization for Hallux Limitus
  27. Metatarsal Doming
  28. Abductor Hallucis Strengthening
  29. Flexor and Extensor Hallucis Longus Tendon strengthening
  30. Night Splints and Yoga Toes
  31. Correct Toes
  32. No Achilles Tightness
    Spica taping is a technique with several variations that primarily limits the bend, or dorsiflexion, of the big toe joint. One of the variations is to help the same tape align the hallux that is drifting lateral causing lateral impingement. Spica taping is commonly learned with KT tape or RockTape since it goes around the bends of the toe fairly easy. If the patient needs more restriction, and has the basic skill down, then 3M Nexcare Waterproof Tape is used. This is a skill I want my patients to learn and perfect. It is part of my initial experimentation into what helps eliminate the joint pain. Typically one inch wide tape 7 to 8 inches long is centered dorsally over the top of the hallux. First the medial leg is brought down under the big toe joint and then run under the first metatarsal. Second the lateral leg is brought down under the big toe joint, and then run parallel to the first strip along the orientation of the first metatarsal. At least one half of the lateral leg should be touching the skin so that the tape can last 3-4 days. Make sure with KT or RockTape that you then rub in the finished product for a minute to activate the glue. The big toe itself when you are finished should be just slightly below the 2nd toe. Spica taping is classic for hallux rigidus and turf toe, but can hold the toe down with sesamoid injuries distributing the weight bearing somewhat away from the sesamoid. Spica taping can increase the compressive forces across the joint, which may hurt, so you just have to try to see if it makes sense.
    Bunion taping is a technique done the same as the spica taping except with different starting point and leg orientation. Bunion taping is done to center the hallux in the joint when the hallux is drifting or chronically too lateral. Done with the same tape as spica taping, the center is placed on the lateral side of the hallux with one arm going superiorly and one leg inferiorly. When applied, the hallux is placed in neutral and first the plantar arm comes under the big toe joint and laid along the medial side of the first metatarsal. This is where you and ultimately the patient has to play with how tight. It can be a balance between good correction and too much pressure. The superior arm then comes across the joint and again is laid down on the medial side of the first metatarsal with about half touching new skin and half overlapping the other arm. Remember to rub in the tape for a minute to activate the glue, especially if it will be left on for a few days. Bunion taping is done post 2nd toe surgeries when you do not want the big toe applying pressure on your surgery. It not only centers the joint, but does some restriction of the joint motion that is less than spica taping, but has some effect.
    Toe Separators (sometimes called toe spreaders) come in various shapes and sizes and materials. From the hard rubber ones that I was first exposed to as a student, now they are made of soft foams and gel. To me, a medium gel toe separator that has the shape of an hour glass is conservative bunion care 101. My mantra in bunion care is maintain stage 2. The toe separator immediately puts the bunion, which may have started the day in stage 3 or 4, back into stage 2. As you walk, with stage 2 of bunion development maintained, the forces through the big toe joint are more normal and should slow down the hideous retrograde forces. This centering of the joint will allow for normal muscle development as muscles are typically strengthened within a few degrees on either side of the range you use them. If you want to strengthen the right muscle fibers, strengthen a muscle with the joint properly aligned. This centering of the joint also helps alleviate pain from lateral joint impingement, common at the big toe joint. Even joints that do not have bunions can be negatively influenced by shoe gear and activity mechanical forces that shove the hallux laterally. You just have to think how many ballet dancers develop juvenile bunions from the en pointe positioning, especially if pointe is started when they are skeletally immature. Foam toe separators have more width and therefore work better for a lot of my patients. They are long and can go too far forward on the toe and cause ingrown toenails. For this a good scissor can shorten them. With overlapping toes, you either need the hour glass shape of the gel ones, or the toe separator that slips over the 2nd toe and has a toe separator attached medially. The patient should never take their sock off and see the toe separator resting under the second toe. This will worsen a hammertoe problem. Toe separators can and should be used after bunion surgery to help maintain the correction while the muscles and scar tissue are transforming. This is not a good idea if any work was done on the weaker 2nd toe, since the pressure of the toe separator can ruin your toe surgery.
    Dancer’s padding has a fun beginning. In the 1700s, when the French were studying their ballet, they discovered that dancers with big toe joint pain could be helped by transferring the weight off the area. Before then, if your big toe joint hurt, it would be covered to protect it, so this concept was revolutionary! So, instead of calling this padding a Reverse Morton’s Extension (a more popular name), our office honors the French and call it a dancer’s pad. It is a pad that typically goes under the 2nd through 5th metatarsal, but if the 5th metatarsal has issues, then 2 to 4 is utilized. Many materials are utilized, but my office stocks 1/8th inch adhesive felt that can be applied to anything (orthotic device, shoe insert, sandal, ballet slipper, etc). Sometimes to take enough pressure off of the big toe joint and hallux I increase the padding to ¼ inch. If you do, make sure the patient does not feel that they are actually falling into the hole which would make things worse. If you put the second pad on, do not line it up perfectly with the first layer. Off set it alittle laterally and proximally (or distally) which easies the feeling of the edges. It typically reduces the plantar pressures across the joint by 50% or more. Many times the pronation affect of the dancer’s pad to pull a patient medially must be balanced by an arch support of some kind to pull the patient laterally. I prefer OTC non plastic orthotic devices for this since the goal of plastic based orthotic devices, with or without Dannenberg modifications, are meant to make the big toe work better and move more. It just may not be the right time for that when you are trying to off load a sore sesamoid or hallux rigidus. With the recent barefoot craze, with the resultant forefoot impact load at contact, it seemed like I was making dancer’s padding all the time. I joked to my fellow podiatrists that I had to make dancer’s pads for these runners that preferred running as dancers. I typically do not make dancer’s padding that goes to the toes due to crowding issues. I love the Dr. Jill’s Gel Dancer’s Pads. They come in 1/8th inch and ¼ inch, and sometimes you need to make the hole bigger. They stick on one side and are primary for sesamoid injuries. But by making the hole bigger, they can work well for any big toe joint problem. The stick side allows you to use them on your skin or any surface. Because of that, you need several rights and several lefts of each side to really have all the combinations going forward. If you place a ⅛ on one side, you usually do not need anything unless you feel awkward on the other side. If you place a ¼ inch on one side, you at least need ⅛ inch on the other side for balance.
    Cluffy wedges was designed by Dr. James Clough (play off his last name) in Oregon. It is a small pad that fits into the sulcus under the proximal phalanx to off weight the sesamoids (big toe joint) as your weight rolls forward. The ⅛ inch adhesive felt is usually 1 inch by 1 inch or slightly smaller. It can not go under the distal phalanx or it increases big toe dorsiflexion and big toe joint weight bearing. I never used it until 10 years ago when a patient of Dr. Clough moved to San Francisco and needed a new podiatrist. She was wearing her cluffy wedge as part of a fractured sesamoid treatment. When I asked her if it was helpful, she stated she would not leave home without it. So, it became part of my treatment from that point on, and like most of these mechanical treatments, 50% of patients feel that it is very helpful. Dr. Clough, one of my students, was in the same class as Dr. Kevin Kirby, biomechanics guru extraordinaire, but when the cluffy wedge works successfully, it is Dr. Clough that I am most proud of (at least for a second or two). So, when patients present with big toe joint pain on their first visit to my office, they all leave the office with a game plan and 3 mechanical changes to begin to manipulate the symptoms: spica taping, dancer’s padding, and cluffy wedges.
    Morton’s Extensions put more pressure on the big toe joint and hallux, but are used to immobilize the joint with hallux rigidus (arthritis). They can involve the big toe joint and whole hallux, or end at the interphalangeal joint. They can be an extension off the distal medial end of an orthotic restricting the bend between the orthotic device and forefoot extension or just a loose attachment distal to the plastic orthotic device. Morton’s extensions can be a varus wedge for the forefoot in certain biomechanical conditions even if just a 1/8th inch. Morton’s extensions can soft or hard, ⅛ th inch to ¼ inch, and of varying degrees of rigidity. Morton’s extensions, like dancer’s padding, can be applied to custom orthotic devices, OTC inserts, or simply the shoe liner. In general, Morton’ extensions are used in the Immobilization Phase of an injury, for joint restriction or immobilization, but not in the long haul. Eventually, you have to free up the joint. Morton’s extensions block normal motion. I have many patients who need a Morton’s Extension as a cast while we are calming down a joint, probably as we transition from cam walker, post operative shoe, or Hoka One One rocker bottom shoe type. Many of these patients, if they get recurrent problems, or are left which some joint sensitivity, have 2 versions of orthotic devices. They need a Morton’s extension arrangement and a more standard dancer’s padding arrangement.
My mantra is to maintain big toe joint mobility unless forced into it. The long term problems of compensation if the first metatarsal can not plantarflex is huge. In summary, the rules of Morton’s extensions:
  1. Use for the shortest time possible in the Immobilization Phase of big toe joint pain.
  2. Use as a Forefoot Varus Wedge in some athletic activities, like propulsive phase pronation in runners (in their running orthotic device only).
  3. The rigidity (or immobilization) can be increased with attaching it to a orthotic device, using firmer materials, or extending it longer to the end of the shoe.
  4. The rigidity (or immobilization) can be increased by using it with bike shoes with embedded cleats, Hoka One One rocker shoes, stiff soled hiking shoes, and hunting boots.                                                                                            
    Orthotic Devices for Weight Shift with no extrinsic post are used by the majority of podiatrists I know for big toe joint pain. As we stand, our tripod of support includes the heel, first metatarsal head, and fifth metatarsal head. So, if we have a problem with the big toe joint, we typically have to change that dynamic to distribute pressure throughout the foot. Extrinsic posts, used in some classic orthotic designs, are removed or never ordered from the lab when a patient has big toe joint pain since the post may shift the weight forward enough to increase the pressure on the joint. It is easy to put on at some point in the future. I love it when the orthotic device can capture a lot of architecture along the lateral column and metatarsals. I do not like weight bearing casting here, since these impressions flatten the metatarsal architecture. Definitely when using functional foot orthotics on a patient with big toe joint pain, there are some design concerns. I think you should design your orthotic device based on the biomechanics you want to correct, and then add all the additions we are discussing like dancer’s padding, or Morton’s extensions. But you should know the factors which have an impact. These factors that affect the success of your orthotic devices on big toe joint pain include:
  • Whether the rearfoot and arch has enough support to shift the weight laterally off the big toe joint.
  • Whether the medial arch increases the plantar declination of the first metatarsal increasing the load and bend of the first metatarsal phalanges joint (I tend to use Kirby Skives a lot here with minimal medial arch height in some of these cases).
  • Whether the stress at the end of a standard orthotic device will produce too much stress on the big toe joint. Remember when a device supports and protects and immobilizes something, the most stress is where it ends. It is a natural stress point. Just like the old acrylics used to break right in front of the rear foot post.
  • Whether the natural motion of the big toe joint needs to be immobilized more. If you think of things that orthotic devices make move or function better (big toe joint and posterior tibial tendon for example), then it should not be surprising that they can hurt more because we are letting them move or function too much. There are times that tissue should be in the Immobilization Phase instead of the Return to Activity Phase. The tissue has been injured and just not ready.
    Orthotic Devices of Stability only with no extrinsic post is a common custom or over the counter device prescribed for big toe joint pain. The difference from the last example is that there is noticeably no attempt at varus wedging in any form for weight shift. These orthotics flood my office for outside practitioners, or may be over the counter types, and they may be perfect, or just need something more. Typically these orthotics do not make the big toe function better, so may not stir up the joint. They may not shift the weight enough, so dancer’s pads, spica taping, cluffy wedges, more arch support with Hapad arches, temporary Kirby Skives that you can place in the office, varus wedges added to the plantar surface. As you work on the inflammation and nerve hypersensitivity, continue to work on the mechanics. Remember all the causes of big toe joint pain from a mechanical viewpoint: compression forces, plantar loading forces, joint malalignment forces, superficial shoe forces, and bending forces. Identify these forces that apply to your patient and gradually make changes. See what works. You may discover that a different design is going to be the best, but I typically use what the patient brings in and try to customize that first. It works in a great many times.
    No Heel Lift is the general principle in treating any metatarsal problems including big toe joint pain. It can be a challenge when the heel lift is for the short leg which just happens to be on the side of the big toe joint problem. This can be remedied by making the lift into sulcus length with a cutout for the big toe joint (lift with dancer’s pad combined). Lifts can also be part of a custom orthotic functioning as an extrinsic rearfoot post for improved medial and lateral instability. When dealing with big toe joint pain and orthotics with rearfoot posts, I remove the rearfoot post and place midfoot medial and lateral supports to hold my correction as best as possible. I use a grinding rubber ¼ inch in the medial arch and ⅛ inch under the cuboid/5th metatarsal base. The heel lifts may be on both sides and function more as Achilles supports or heel pain cushions. At times, you have to decide what is the worst pain for now and make the appropriate adjustments. Of course, for women, and even men who wear cowboy boots, shoes with heels should be restrictive for months longer than it takes the big toe joint pain to resolve.
    Zero Drop Shoes is along the same lines as no heel lifts within the shoes. Starting with racing flats for runners, or dress shoes for men and women, there is now a plethora of athletic shoes from minimalistic to maximalist that offer zero drop or close to zero drop shoes. This means that there is zero to 4 mm in general transition downward from the heel to the forefoot. The traditional running shoes like the Brooks line typically are 12 mm transition or greater in some shoes. But, this is like everything we have been talking about. Some patients need this and others not. As podiatrists we now have so many choices and this variable can be helpful. The only running shoe company I know that that is exclusively zero drop is Altra. When the zero drop shoes are too soft in the heel, they can produce a damaging negative heel effect.
    Rocker Shoes have been popularized by the Hoka One One shoe company and are a must shoe to try for my big toe joint patients. There are so many styles and configurations of the padding and rocker that patients have to go to a store that have many variations. The position of the rocker has to be just right to roll the patient gently across the injury and not put pressure on the injury. Some of the shoes will naturally put a slight varus bias in the roll which may help until they break down laterally. Some of the shoes have just the right amount of cushion and stiff, others something is off. Hoka One One is only one of the companies with a rocker, as the New Balance 928 and the dress shoe line Allegria also have them. I am sure at the time you are reading this many more companies and styles will be available. The rocker effect is so much better than the rockers we used to ask shoe cobblers to put onto shoes. My patients would trip and fall on these things that stuck out on the bottom of the shoe and I got very frustrated with them. A negative, among many, of rocker shoes is sometimes the heel is too unstable. The patient should roll through the shoe without sinking back into the heel. This negative heel effect, like the original Earth shoes, is very damaging, and can be felt in some of the zero drop shoes as mentioned above.
    Bike Shoes with embedded cleats have been a wonderful find for my practice. The company Chrome, with a headquarters in my San Francisco, makes gear for the bicycle messenger industry and have a line of non-athletic looking bike shoes that can pass as semi-dress shoes. Other companies like Shimano or Pearl Izumi have these mountain bike shoes, also called hike and bike shoes. The cleat is embedded so you are not walking on awkward cleats. For big toe joint problems, and plantar fascial tears, when you want to restrict the bend of the big toe joint for 3-6 months, this can be a lot better solution than a cam walker with an EvenUp on the opposite side. I have irritated so many less backs then with the removable boots. During the rainy season, sometimes these can only be used indoors as they can be more slippery than a normal shoe with rubber traction. The motion in these is abnormal, using more hip and knee motion since you can not push off, but since they are used as a pair, the lack of asymmetry tends to work well. Remember we are trying to attain the 0-2 pain level so the injury can heal. Even if the patient is in a boot for a while to drive the pain down, these shoes or Hoka rocker shoes may be the transition before normal shoes. And, you can wear your orthotic devices, dancer’s padding, cluffy wedges, spica taping, etc. with this shoe and with the removable boot. Do what you can to drive the pain down as quickly as possible.
    Cam Walkers (Removable Boots) are the classic treatment of all big toe joint problems as the patient limps into your office and painlessly strolls out. You are starting the several month process of discovering the diagnosis (over treat please until you know that it is not a fracture), protecting the foot, and creating the 0-2 healing environment. Even without all the information, you can wonderfully start the patient on a road to recovery on day one. The 3 phases of rehabilitation are Immobilization, Re-Strengthening, and Return to Activity. The phases are blended all the time, but do not blur the distinctions of the 3 phases. Know when they are in each phase, even when you start them strengthening on day 1, and you place them back in a walker during a flare in the Return to Activity phase. When someone has injured their big toe joint, any imaging like x rays possibly suggesting arthritis vs sesamoid irregularities are not conclusive, how do we create a healing environment? The cam walker stops the bend of the big toe joint. Up to a ¼ inch adhesive felt can be placed into the walker to off weight the area. I have had too many patients come in for second opinions because the boot was the right idea, but the patient remained in pain walking in the boot. I explain to the patient that the pain has to be 0-2, walking a good deal, for 2 weeks straight, before we can think about transitioning them into bike shoes, or Hokas, or normal shoes with inserts, etc. Yet, certain diagnoses, like sesamoid fractures override that rule and require in my mind 3 straight months of immobilization before we loosen the reins. One more point about cam walkers concerns full day or partial day use. If the restriction of the boots eliminates pain, you can use it for short periods of time to just rest the tissue. Sometimes my patients will only be in the boot for 4 hours a day presumably a stressful time of the day for their injury. That can give the injury valuable rest time to help the healing process. I learned this well with my dancers at San Francisco Ballet, where they would full their full dance but spend the rest of the day resting the injury in the boot. Sometimes it was part of a medical compromise, and sometimes only an extension of the 0-2 pain level that we were achieving other ways.
    Stiff Soled Shoes (including post operative) are something every podiatrist has in their office. These can immediately stop the bend of the big toe joint in the acute phase of an injury. When a patient injures the big toe joint, you have to remind them not to bend their big toe joint. They have to walk flat footed. Many patients have to use off weight bearing padding in these also, as just stopping the bend of the joint may not be enough to reduce their pain. So many patients have stiff dress shoes (like flat forms) or stiff hiking or hunting boots that can serve this purpose. Shoe cobblers can stiffen the forefoot in some shoes, and I would try to find one with padding and hopefully a removable insert. The extra stiffener can be removed when not needed at a later date.
    Flexible Shoes is the complete opposite of the above stiff sole option, but sometimes what is needed. Some patients put a lot of force through their first metatarsal phalangeal joint with walking and they need the shoe to be flexible and less stressful when they try to bend the joint. I am not sure if these are patients with more pronatory or supinatory gait patterns, but I assume supinatory since they are more central in their weight distribution across the metatarsals. The more pronation with over loading of the big toe joint the more stiffer the platform would have to be to protect it. Of course, it depends on all the other factors like do they use inserts with dancer’s padding, etc. When I send patients to a good shoe store to pick up some Hoka One One shoes, very stiff and very rocker, they are to put everyone we have designed in the shoe, and compare to their traditional flexible shoes. With the insert and dancer’s padding pulling their weight bearing lateral, some of these patients feel great in their traditional flexible shoes. I tell them to still get the Hokas, but alternate back and forth daily, with each shoe environment relieving the stresses produced by the other shoe environment. I love varying the stresses as long as I can keep the pain level between 0-2.
    Forefoot Padding is the opposite option of dancer’s padding or reverse Morton’s extensions. It an area is sore, pad it, and see if it feels better. So many patients have poor fat pads, especially near their bony first metatarsal heads, and the extra padding is of great comfort. In my office lab, I always have around 5 types of cushion material around ⅛ inch thick that I can add to the forefoot or heel in particular. Here I am not talking about localized padding to create a Morton’s extension or a Reverse Morton’s Extension, but a simple pad across the entire ball of the foot for more cushion. When patients like that for their injury, you know they should like shoes with a lot more forefoot padding to separate the pedal from the metal. Hannaford style cushion orthotics are full length memory foam orthotic devices that maximize the forefoot padding for these patients.
    Skip lacing can dramatically take pressure off the big toe joint. The distal medial hole may or may not be over the big toe joint, but it can still produce pressure downward from the top. This the same concept as finding the shoe with the deepest toe box as later described. You can skip both the medial and lateral last two holes distally, or you can attempt to just skip the medial hole for the maintenance of the best shoe stability. When do this, first you take out all of the laces except the most distal (closest to the toes). Make sure that the laces are even. Take out only the lace that runs through the hole near the big toe and transfer it through the hole one above (proximal) still on the medial side and then through the hole directly lateral (if you are counting from the bottom, medial second and then lateral second holes). If you think about it, if you had placed it originally in the distal medial hole, it then would have ended up here in the second lateral hole. The original distal lateral lace will also go through the second medial hole, so 2 laces through the same hole. From this point on, the lacing is normal up towards the ankle. You have succeeded in alleviating pressure from the top down onto the big toe joint. At times, with such acute problems like a gout attack to the big toe joint, you have to remove the last 2 holes, medially and laterally, so go to a shoe with Velcro closures like post operative shoes.
    Deep Toe Box unfortunately only occurs in a few selective shoes like some of the Brooks shoes. There are a slew of diabetic shoes that are extra depth, like the Ambulators, that can create space for a very protective shoe insert. In most cases, when I give a patient a list of shoes for a big toe joint problem (say neutral, stability, or motion control), I simply ask them to try to find the one that gives the most room in the big toe joint area that is still their correct size. There can be enough differences in shoes that one shoe may be better in this regard. Since shoe selection and unique features are very difficult to keep up with, the advice of the store personnel can be vital in the decision making.
    Wide Toe Box is an easier concept for the patients to grasp when selecting shoes then deep toe box. Some shoe companies run narrow in general, like Nike and Hoka One One, some run wide in general like Altra, some have narrow heels and wide forefoot like Saucony, and the trend that New Balance started offering various widths in each size. There are now so many variations across a shoe line that some of these general rules do not quite fit, with a knowledgeable shoe store a must in your treatment team. It is crucial that a shoe is the most stable in the medial midfoot. Instability in this area causes a breakdown in the entire medial column support of the entire lower extremity. Many patients break this rule by getting into a shoe that is too wide not only for the big toe joint, but for the entire width of the foot, and they swim around in the shoe too much causing worse problems like knee pain. I have had patients come in 2 sizes too big just to get the width in the forefoot. To get these patients back into more  appropriate sized shoes, or at least to stabilize their feet more, the following usually helps:
  • Skipping Shoe Lace
  • Power Lacing
  • Proximal Padding (dorsal or medial)—to be discussed soon
  • Custom or OTC Arch Supports for medial column support
  • Finding a shoe with no seams or reinforcements in the bunion area
  • Removing any padding under the big toe joint (like cutting a half circle from the shoe insert)
Occasionally this problem happens with the smaller foot of a patient with a big difference in foot lengths. You have to buy for the longest foot. As of this writing, the Brooks company will split boxes for a small fee even if the size difference is only ½ size.
    Shoe Stretching can work at times in a dress shoe to take pressure away from the dorsal or medial aspects of the first metatarsal head. It has been my experience that it only works when the shoe cobbler takes the shoe overnight to stretch. The ball and ring stretchers are still in use in many podiatrists office, but there is a skill to make the area stretched cosmetically appealing. I have not seen this work in athletic shoes, but some cobblers can remove irritative seams or bands of material that are in the way.
    Carbon Plates (Full Width) are thin rigid plates that come in all the sizes of shoes that fit under the shoe insole or orthotic device to limit toe bend. It is a simple way of taking a flexible shoe and making a temporary rigid shoe (as long as you need it). The design I use is totally flat (Otto Bock) and can work like a charm, or have major difficulties matching the curves and design of the present shoes. 2 local stores sell these and find good patient feedback. Since it does not allow your foot to bend at push off, I recommend it on both feet, which creates less asymmetry. In rainy weather, when a bike shoe with embedded cleat is not possible, this is a good alternative if you can find a shoe that it works with smoothly. Like the bike shoes you are supposed to not push off, but lift from your hips and knees (like marching). If the patient can not break the habit of trying to push off, or if they pronated too much into the plastic plate under the big toe joint, they will feel worse with this and should remove it quickly.
    Carbon Plates with Morton’s Extension work well with an orthotic device on top. Here only the first metatarsal head and hallux have the carbon plate distally. You want a varus biased orthotic device that gets you into the middle of the foot well. However, with some severely pronated feet, this is nearly impossible. If you can get the weight more central, this device works well allowing normal motion without big toe bend and it is appropriate to only use on the side needed due to big toe joint pain. A common problem with this design is when the hallux is too lateral and falls off of the plate. Sometimes you have to use bunion taping (as previously described) and/or toe separators (also previously described) to get the hallux over the Morton’s extension. And again, if the patient pronates too severely into the Morton’s extension, the pressure can be too much, and may be more a candidate for the next design.
    Carbon Plate Dancer’s Modification is definitely my favorite design. It limits the big toe joint and big toe pressures, it limits the motion in general across all of the metatarsal phalangeal joints, does not lift up on the first metatarsal adding to its overall pressure, but it does allow more big toe joint motion, and that could be the source of pain. You can also spica tape with it. You can actually put this under the shoe insole on the first visit, spica tape, add some Dr. Jill’s dancer’s pads, and probably help most patients before they walk out the door. I always want to free up the big toe joint by various means before attempting to limit it when it is the only way to get to the 0-2 pain level. I must emphasize that  in my office, one thing is done at a time. You must do one thing at a time, watch the patient walk and/or run, get the patient’s feedback, then you can add or subtract another modality. This is the only way you can separate what is helping and what is not helping.
    Proximal Padding (dorsal or medial) is an off weighting pad typically one inch square that attempts to place pressure from a sensitive spot (say medial eminence on a bunion) to a more proximal ( or less sensitive) spot. I typically use ¼ inch adhesive felt, but sometimes ⅛ inch is enough. I typically try in the office, and if it helps, give them a foot of material. Each square can be used 3-4 times before the stick wears out. It is only used when they wear enclosed shoes that could press on the area. Of course, some tight shoes can not fit anyway else, barely fit the foot itself. And, sometimes, you have to make the design smaller so that it will not show. When it comes to taking pressure off a sore area, sometimes very little is needed. Proximal padding is used mainly for the big toe joint area when there is medial bunion pain and dorsal spur pain from hallux rigidus. A very important aspect of bunion care is to off weight the medial eminence, but also vitalize the medial eminence soft tissue. Chronic inflammatory changes at the medial eminence can lead to skin breakdown and nerve hypersensitivity. Daily 2-3 minute non painful massage with hydrating lotions can help mechanically move away inflammatory tissue and de-sensitize the area. I will even send patients to physical therapy to help the tissue get healthier.
    Metatarsal Padding (sub 2nd to 4th or 5th) is another method of shifting weight from a painful big toe joint. The difference here from a dancer’s pad is that the weight is placed on the metatarsal shafts not metatarsal heads. I tend to use small or extra small Hapad longitudinal medial arch pads and apply them onto shoe inserts, over the counter orthotic devices, and custom orthotic devices. I actually first used them in ballet slippers and en pointe shoes when I routinely treated the San Francisco Ballet and the Oakland Ballet. You can not put much into those shoes, so what you do use has to be powerful. I typically have to thin them out some, and the patients are advised how to do so. There is a website and fax number on the backing where they can find more. The goal is to keep the weight centered through mid stance and propulsion, limiting the weight through the big toe joint and hallux. Changes from 50-60% weight to 40-50% weight can make a big difference over several weeks at letting tissue heal. Patients need to roll through the ball of their feet, notably the second metatarsal head onto the distal phalanx of the hallux, in active propulsion. The weight bearing is generally moving from a lateral (or sometimes more central) heel strike to a medial push off. These metatarsal pads can help redirect that force more central, or at least share more weight bearing onto the other metatarsals and unload the big toe joint some. Some may be enough to help, and help dramatically. After you take the backing off the Hapads, you have around two days to move it around until the adhesive gets too stuck. The patients are advised that they can move the padding medially or laterally and anterior or posterior. They should never feel like they are falling into the big toe area like falling into a hole. Sometimes, the position that feels the best for them, I would never have placed there.
    Self Mobilization for Hallux Limitus is a gentle tool that patients can learn when the range of motion of the big toe joint is limited. The more natural motion I can get out of a joint the better. The technique of self mobilization was taught to me by Drs. Rue Tikker and Timothy Shea and has been a valuable part of my practice for 40 years. I remember clearly this one patient who came in fairly distraught at the limited range of motion she had after bunion surgery. We all know that over 60 degrees of first metatarsal phalangeal joint dorsiflexion is considered normal, and you need 75 degrees of motion for the wearing heels and most sporting activities. She had 41 degrees of big toe joint dorsiflexion. I taught her self mobilization and she improved the range to over 70 degrees over a 3 month period. Of course, I had taken X-rays to make sure that there was no bony restrictions. The principle of self mobilization is short, quick motions in directions that is not normal for the joint to move. So, to improve dorsiflexion or plantarflexion of the big toe joint, and to naturally break up some scar adhesions, you perform four motions:
  1. Dorsal and Plantar Gliding
  2. Side to Side Rotation
  3. Clockwise and Counter Clockwise Rotation
  4. Long Axis Extension
These are done quickly, so it is Grade 5 mobilization that you are teaching. I do them twice, and always feel that the joint is looser the 2nd time. I measure before and after mobilization and typically get 5 and sometimes 10 degrees gain. The patient must do it 3 to 4 times a day to slowly gain, and maintenance for some will be once a day indefinitely. If I start a patient doing this, it is measured every visit even 5-10 years down the line to make sure they are not slipping back. The principle of mobilization is to stabilize the proximal segment and move the distal segment. So, you stabilize the first metatarsal head so that does not move, and you grab the proximal phalanx of the hallux. Remember you are moving the proximal phalanx on the first metatarsal head in 4 ways it does not normally move. You glide it up and down, you abduct and adduct, you rotate like a clock both directions, and you pull it out straight. The last one can be the hardest angle for the patients to do, but they try.
    Metatarsal Doming or Arcing is the best way to strengthen the flexors (hallucis longus and brevis) along with Single Leg Balancing. Metatarsal doming is an isometric exercise with tightening for a six second count with 4 second relaxation and then repeated 10 times total. You can do it 3 times a day, but a conversation I had with Dr. Pribut from Washington, DC, says he has his patients do them up to 300 times a day. The first part of the exercise involves straightening all of the toes. Patients with bunions and hammertoes that they can not straighten actively, need toe separators and/or Budin splints to get everything in a straight(er) position. You want to strengthen the correct muscle fibres that pull the toes straight. With the toes straight (reasonably), you pull up on the metatarsal heads keeping the tips of your toes against the ground as you count to 6. Try to feel the tension in the metatarsal arch as you squeeze the tissue as you do in every isometric. That squeeze feel is developing muscle bulk and tone, and patients begin to feel the difference in their feet within weeks. This is different and more powerful for straightening then picking up marbles or crunching a towel. I personally think these later two exercises can make hammertoes worse, but I have also seen good strength gains when patients are doing them. I prefer when patients are learning these that they carefully watch that their toes are not curling. Once they are doing the exercise correctly and consistently, they can do it in the supermarket checkout line, etc, without having to look down.
    Abductor Hallucis Strengthening is for bunion deformities when the decision is conservative care for the short or long term. It is actually a variation of metatarsal doming. It is not straight abduction, more like abduction plantarflexion, but it does get the abductor hallucis muscle fibers working and stronger in the process. Anyone who has seen an MRI image of the abductor hallucis muscle belly knows how huge it is and how powerful it could be putting a medial pull on the hallux. As a bunion develops, and the medial side of the first metatarsal head gets stretched, while the lateral side tightens, a natural muscle imbalance occurs with the adductor hallucis at an advantage. This is made worse as the first metatarsal drifts dorsally, moving the abductor hallucis more plantarly across the joint, weakening the medial pull further. For this exercise, you need a small 3 inch section of level 1 Theraband that you tie together the ends to make a loop. The loop is then placed around each big toe, and the feet are separated until the big toes are in a straight position across the big toe joint. With one foot metatarsal doming at a time, and other foot immobile, the same motions of toe straightening then metatarsal arcing is done, 6 seconds tighten 4 seconds relax 10 times total. This should not be done if the joint is already sore. The patient should pull on the big toe in a comfortable manner and may not be able to get the toe perfectly straight. There should be no pain in doing this exercise. If the patient is just starting with night splints, toe separators, correct toes, yoga toes or gems, they will see an improvement in toe position overtime. Also, lateral capsule deep mobilization with a physical therapist can get us on the right road sooner is really stuck cases of Stage 4.
The exercise, like most strengthening exercises I show patients except pure metatarsal doming, is only done in the evening within 2 hours before going to bed.
    Flexor and Extensor Hallucis Longus Strengthening can be very important in many big toe joint injuries. Making sure the long flexor is strong in sesamoid injuries helps protect the plantar surface of the joint. Making sure the long extensor is strong in Hallux Limitus or Rigidus conditions maintaining dorsiflexion strength. Typically, when any joint is injured, strengthening all the important muscles that run across that joint is important, with one group more important than another. Many podiatrists delegate this role to physical therapists which is wonderful, but try to analyze where the importance lie and what muscles are going to help the most. My mantra is to begin strengthening as soon as the injury happens. The muscles involved weaken at an alarming rate of 1% daily with any injury, and strengthen ¼ to ½ % daily. Even simple active range of motion strengthening, like moving your big toe up and down 10 times, can activate the muscles that get lazy or shut down due to the pain of the injury. Level 1 or 2 resistive exercise bands can be used to wrap around the big toe at the level of the proximal phalanx, and 2 sets of 10 toe crawls are done against the resistance of the band. For the long extensor, the resistive band has to be attached to an immobile object like a bed post with a rope attached to the post attached to the band. The band will be parallel to you in straight line with your leg. You will then wrap the big toe and start with sets of 10 against the pull of the band. There is more information on strengthening that applies in Chapter 5. Again, any strengthening as to be done pain free, but should be started as soon as you can.
    Night Splints and Yoga Toes are two interesting products that can help big toe joint problems. The best night splint, or at least the one that is most comfortable, has a soft plastic that is sold at Night splints are to gently stretch the lateral capsule of the big toe joint when their is stage 3 or stage 4 bunion development. Because they have velcro, you need to wear a sock when wearing so that the Velcro does not attach to anything while you are sleeping. Physical therapy to perform lateral capsule loosening can be an important part of this treatment. This stretch of the tissue for a prolonged period of time each night can be very helpful at then allowing the toe separators to work better. If any conservative treatment for bunions is to work, you must consistently get the bunion into stage 2. Yoga toes came onto the market 10 plus years ago and has been an incredible help keeping soft tissues from contracting adding to digital deformities. Different from night splints, yoga toes put a straightening effect on all the toes. They are to be worn 30 minutes each day, and you can not walk in them. Some of my patients wear them longer, up to 3 hours in one case, because of the positive effect that has been seen. Slowly over time, as we wear socks and shoes, our toes get more and more deformed, and this is a positive way to start reversing that trend. YogaToe company has recently made two other designs: Yoga Gems (with a less aggressive separation) and Awesome Toes (which are meant to be worn about walking in house slippers, etc). Because of the dominance in the market of the next product called Correct Toes, I have not experimented with Awesome Toes.
    Correct Toes, invented by Oregon podiatrist Dr. Ray McClanahan, is Yoga Toes for walking. When patients have bunions and hammertoes, it is a device that they should see if it works. Presumably born from the barefoot running boom 10 years ago, Correct Toes slips over each toe, gently separating them, and were designed to both walk and run while wearing. Since our feet are naturally wider than the position shoes force us into, and since Correct Toes will place each toe in a very separated position from each other, there are only a select group of shoes that they will fit into. Dr. McClanahan’s website tells the buyer what shoes are appropriate. I tell my patients to look at that list, also start with walking around the house in loose slippers to get the feel of them. Altra and Keen shoes are my go to shoes right now known for their wide forefoot. Even if the patient only wears them for a short time at home, they will get a benefit from them. Some patients have too narrow a foot for the current design, and my most common adjustment is to remove the lateral one or two holes. At least, this is still getting the separation of the 1st, 2nd, and 3rd toes. Many patients have described a greater sense of power at push off.
    No Achilles Tightness is the last in my discussion of big toe joint problems, but in some cases, the most important aspect of treatment. A tight Achilles’ tendon drives a tremendous force downward into the metatarsals, particularly the big toe joint, which the ground reactive forces have to match. This aspect of functional hallux limitus may not be picked up in our examination as it happens from the middle of mid stance into propulsion when the bend of the ankle is restricted by the tight Achilles for the first time in gait. It is why when we talk about vital measurements, Achilles flexibility is crucial to learn. When the ankle can't bend past ninety degrees (more subtle forces as the bend gets closer to 10 degrees) at the middle of mid stance, and as the body weight continues to move forward, the heel will lift up early driving abnormal pressure into the forefoot, or the midfoot collapses driving abnormal pressure into the forefoot, or the foot abducts driving abnormal pressure into the forefoot. Therefore, all forefoot pain patients, especially big toe joint, should have the Achilles’ tendons measured for any tightness issues, and corrected as soon as possible. There is more on this treatment later, but since we are talking big toe joint problems, I want to discuss one important issue. When you stretch the Achilles’ tendons, both with straight knee and bent knee positions, the actual stretching itself can put a lot of pressure on the big toe joint. You can hang the big toe joint off the end of a thick book, so as you stretch no weight goes into the big toe joint. You can also build a well with 4 books arranged to make a float for one spot. Some of my wood working patients have made their own platforms so that they can stretch, do single leg balancing, Yoga poses, etc, and protect the sore joint at the same time. Purchasing a cheap but thick sandal, and then having a shoe cobbler cut out the big toe area, can help patients avoid irritating their joints while stretching, etc.
    Avoiding Excessive Big Toe Joint Bend applies to activities that a patient may do repeatedly that can stress out the injury. Activities like plank, downward dog, running on their toes, putting something on a high shelf, our sitting position, the tightness of bed sheets that can pull our toes up, etc.

Mechanical Treatment 1st MPJ Checklist
  1. Spica Taping                          Utilized____ Helpful____
  2. Bunion Taping                       Utilized____ Helpful____
  3. Toe Separators                       Utilized____ Helpful____
  4. Dancer’s Padding                  Utilized____ Helpful____
  5. Cluffy Wedges                       Utilized____ Helpful____
  6. Morton’s Extension               Utilized____ Helpful____
  7. Orthosis (Varus)                    Utilized____ Helpful____
  8. Orthosis (Stability)                Utilized____ Helpful____
  9. Less Heel Lift                        Utilized____ Helpful____
  10. Zero Drop Shoes                    Utilized____ Helpful____
  11. Rocker Shoes                         Utilized____ Helpful____
  12. Bike Shoes Embedded Cleat  Utilized____ Helpful____
  13. Cam Walkers                          Utilized____ Helpful____
  14. Stiff Soled Shoes                    Utilized____ Helpful____
  15. Flexible Shoes                        Utilized____ Helpful____
  16. Forefoot Padding                    Utilized____ Helpful____
  17. Skip Lacing                            Utilized____ Helpful____
  18. Deep Toe Box                         Utilized____ Helpful____
  19. Wide Toe Box                         Utilized____ Helpful____
  20. Shoe Stretching                       Utilized____ Helpful____
  21. Carbon Plate (Full Width)      Utilized____ Helpful____
  22. Carbon Plate Morton’s           Utilized____ Helpful____
  23. Carbon Plate Dancer’s           Utilized____ Helpful____
  24. Proximal Padding                   Utilized____ Helpful____
  25. Metatarsal Padding                 Utilized____ Helpful____
  26. Self Mobilization                    Utilized____ Helpful____
  27. Metatarsal Doming                 Utilized____ Helpful____
  28. Abd Hallucis Strengthening   Utilized____ Helpful____
  29. FHL/EHL Strengthening        Utilized____ Helpful____
  30. Night Splints/Yoga Toes         Utilized____ Helpful____
  31. Correct Toes                            Utilized____ Helpful____
  32. No Achilles Tightness.            Utilized____ Helpful____
  33. Avoiding Excess Toe Bend.    Utilized____ Helpful____