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Tuesday, August 24, 2010

Hallux Rigidus: Surgery or No Surgery

     Hallux Rigidus means severe wear and tear on the big toe joint. The cartilage is tired, beat-up, and aggravated. The normal motion of the joint is significantly restricted, so attempts to move the joint normally can produce mild to severe pain. There is a lesser version of this called Hallux Limitus, which has significantly more motion, and a different treatment protocol.

     Hallux Rigidus develops over many years, with sometimes smoldering pain episodes, and may never really bother the patient. The joint is actually self-fusing, and getting less vulnerable. I had a great runner as a patient once that was having smoldering symptoms with severe advanced Hallux Rigidus. Luckily he ignored the surgeons, following simple conservative advice, and then proceeded to set a Guiness World Record for 6 marathons in 6 months all under 2 hours and 20 minutes!!

     But, some patients with Hallux Rigidus are not so charmed. They do something, quite ordinary usually, that develops moderate to severe pain. And they have trouble turning off that pain with self methods, x rays taken by the first doctor show the severe arthritis, and surgery is recommended. I maintain that Hallux Rigidus should be treated as a sore joint and nothing else. How do you get a sore joint calmed down? Usually, immobilization to rest the joint, shoes and orthotic devices to limit the big toe joint motion, taping to limit the toe motion, and then pile on the anti-inflammatory measures---icing, contrasts, meds, physical therapy, flector patches, topicals, accupuncture, and injections.

     The treatment of Hallux Rigidus is then divided into 2 columns--immobilization and anti-inflammatory. I challenge the doctors, physical therapists, and other health care providers to do all you can to calm the joint down and get it comfortable, even if this means 3 months in a removable cast (last resort). Once the joint is calmed down, and pain is gone, gradually increase activities pain free. See what it takes to stay pain free. See if there is any disability the patient does not want to live with, that you can guarantee with reasonable degree, would be removed if you did surgery.

     Let us say that you get the joint calmed down, but every time you try to run, the joint flares up. And you want to run, too young to give it up and you are willing to consider surgery. Xrays will show a bad joint with many bone spurs. There is no good surgery with Hallux Rigidus, so if I needed it, I would follow the KISS principle (see separate post). I follow the same thought process as with knees--cleanup with meniscus tears, more cleanup, a third cleanout when needed, a parital knee replacement when needed, and a total knee replacement when needed, and hopefully every surgery is the last surgery. So, with Hallux Rigidus, I recommend a joint cleanout (called arthroplasty or cheilectomy--try pronouncing those), perhaps another joint cleanout, a total replacement, another total replacement, and then a lot of deep thought before joint fusion is considered. Golden Rule of Foot: With Hallux Rigidus, Joint Fusion should be the last resort. 

58 comments:

  1. I am grateful for the opportunity to ask if someone can refer a retired classical ballet dancer, pedagogue and founder/director (of a professional ballet school and company) to a NYC classical ballet specialist foot doctor. I seek a consult regarding my ten (10) year severe hallux rigidus condition that is significantly effecting a myriad of aspects of life, let alone teaching! Sincerely, Bette-Ann blibin@snet.net

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    1. I was diagnose with seronegative arthritis.My fingers were very bad, I find it hard to do normal everyday, I started having pain in my lower back in May 2010. I had X-rays taken at two different hospitals. I was told by both doctors that they can’t see anything wrong. But my back kept getting bad to worse. I took number of treatments, I didn’t get much better. And my legs started getting colder.Now i can't still believe my self really cured from the sickness, oh by this time last year I start feeling bad about my life, I feel pain everyday of my life am very happy now that am really cured I couldn't have do this on my own I wish is not God that help me with my helper I was searching the internet about this sickness last 3 month when I found about this great doctor Ighodalo, the man that keep his words I wrote the man email about my problem immediately I get a reply from him telling me the steps and necessary things i need to do, i was doubting at the first time if it will work out but when i decide to give it a try, i found my self getting much better and i was cured. Am really happy now with my family you can also get your self cured too from this sickness by contact him through his email: dr.ighodalocuringhome@gmail.com

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  2. Can you refer me to a classical ballet centered foot surgeon who treats Hallux Rigidis in professional dancers. I live in CT but am willing to travel for the right approach by the right doctor for my specific needs as a dance educator, school owner/director, company director. The pain is electrifying and ever present, weight bearing or not! Eight (8) years into diagnosis, the wear, friction, non lubribrication of essential metatarsel joints...and an active teaching schedule makes for a tough go with HR. Many thanks for any guidance you can provide. Best to you, Bette-Ann

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    1. Dr. Wen Chao in Philadelphia. She treats all the ballet dancers.

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  3. Dear Bette-Ann, I know alot of podiatrists which specialize in sports medicine in your area, but you would have to call their offices to see if they work with professional ballet dancers. The President of our Sports Medicine association is Karen Langone, DPM in New York, and Richard Braver, DPM is in New Jersey. In Connecticut, there is Jeff Yale, DPM, in Ansonia, Neal Zomback, New Haven, Michael Sabia, Stamford, Ellen Golden, Greenwich, Carmen Luciano, Monroe, and also David Davidson in Amherst, New York. If you call around to their offices please mention my name as the referring doctor. Please let me know what you find out.

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  4. I have been told I have Hallux Limitus in the right big toe and have formed a little spur on top (as least that is what I was told). I get varied opinions from surgery to orthodics. I have also noticed that I feel like I am walking on the outside of my right foot and seems to cause ankle/knee pain =- which one doc told me I was compensating for my toe.

    Just wondering what specific steps I take to heal this as an injury as you suggest! Are their docs who agree with you or a place to find on the net action items I can do?

    Dale

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    1. Have you gotten surgery or had any improvement with your hallux limitus symptoms since you posted? I think I've developed a similar condition and I was wondering how you might be doing!

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  5. The best place I know to go for ortho consult and/or surgery is the Hospital for Special Surgery. I suffer numerous ortho problems - all dance related, and many of them long-standing. I recommend Dr. John Kennedy at HSS for foot/ankle surgery - he was the ONLY doctor who properly diagnosed my ankle condition - a ruptured ligament - and reconstructed it. He worked with the Boston Ballet for several years, and is an athlete himself. I also had a total knee replacement with Dr. David Mayman, also at HSS, and am doing splendidly. Good luck. Donna Marie.

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    1. I am a new patient of Dr. Blake - who is fabulous. I also highly recommend Dr. John Kennedy - who said no surgery yet. We are doing PRP injections (they are working) and Dr. Blake has made 4 pairs of fabulous orthotics and given instructions that will let me dance without surgery. A one-two winning combination.

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  6. Dear Dr. Blake,

    I am a 40 year old women with Hallux-Rigidus (due to a raised first ray bone) that has become very painful over the last 10 years (I only recently found out that this pain was due to my first ray being so high and the joint not fitting properly). I have had 4-6 cortisone injections in the great toe joint, some with great results and others not so great. I do Bikram yoga 4-5 times a week and it has become increasingly harder on that great tow joint ( iam addicted to bikram and don't want to stop!) Could be the cortisone wearing off as I am due for another and will get one this Monday.
    I have seen 2 different pediotrists at Kiaser and both have recommended surgery where the shorten and lower the first ray - THis means 6-8 weeks non weight baring, 6 months to 1 year to heal - Ugg. Or fusion. In my case do you still say surgery is a last resort, would you agree with what these Dr.'s have told me (knowing you haven't seen my xrays)? I would like to be able to wear a hight heal at least 3 inches SOMETIMES and I wonder if I can ofter these surgeries - I can now, sometimes only when I have an injection and then it is only when there is no pressure on the great toe joint from the top of the shoe bed, i.e. a high heeled flip flop (open toe bed). Or is it possible to fuse the great toe joint with the great toe elevated a bit to allow for a bit of a high heel. I know that the high heel issue is the least of my worries, but I am still a woman and still like a heel ;-)
    Thank you in advance for your thoughts.
    Very best,
    Trista
    (San Rafael, CA)

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    1. Trista, What have the doctors said about the joint? Do you actually have Hallux Rigidus, which normally requires some sort of surgery if you are routinely using cortisone to get by. Cortisone in this scenario can postpone surgery for many years. If the cortisone stops working, you can still try a removable boot for 2 to 3 months to attempt to calm the joint down. If the first ray is elevated, you can get by with padding under the first metatarsal to bring the ground up to it. Get 1/8th inch adhesive felt from Moore Medical and begin to experiment. Perhaps the podiatrist you see has some to lend you. If you love Bikram yoga, you would hate a fusion. I would love some of our readers to tell us what life is like following a fusion. I only know a couple of patients who have had it, with mixed results. Before fusion, I would try what they say with joint clean out, also called cheilectomy, and if unsuccessful try a partial joint replacement. I have patients with these artificial joints do well for years. And they do fuse the joint for either flats or heels, and I think that there is a range of heel heights that each allows. Rich Blake

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    2. I am a 50-year old woman who has/had Hallux Rigidus. It started in my right foot and progressed over a few years. By the time I got in to a podiatrist, it was too late. We tried a mechanical toe separator to try to get the toe straight, we tried orthotics. Then, my joint fell apart and broke while I was up at Sturgis. I have had 5 surgeries on that joint -- each time, my big toe got shorter and shorter because she was trying to fuse the joint. I've had pins, screws (one of them worked it's way out -- that was fun), a bone stimulator, the boot cast, crutches, wheelchair -- you name it. This was an 18 month ordeal that I never want to go through again. That joint finally fused on its own after the doctor took everything out, but it was 18 months of hell (woke up in the middle of the 4th surgery and screamed for the remainder of it because the anesthesiologist was a qwack and didn't know how to do his job, and developed a post-op infection after the last surgery). My joint doesn't hurt anymore, but, obviously, it does not move. This means that my foot now rolls out, trying to avoid that rigid joint, which has caused me to have to have knee surgery on the right knee. I also now have an ankle and back problem, with sciatica down the right hip and leg. You can't wear slide on shoes because your toe can't grip (most people aren't aware of how your toes grip because the never have to think about it). You can't wear shoes that bend too much near the forefoot because you will be in agonizing pain. Pretty much, the rest of your body is going to try to compensate for this important joint not working anymore.

      My left foot is also affected with Hallux Rigidus. It came on the same way the right foot did, only later. It is now at the point where there is moderately severe pain and no motion. There is only one step more before I'm back to where I was with my right foot, and that is the point at which the joint breaks. My left foot rolls out, too, and I have already had surgery on my left knee (before the foot problem), and my left knee is ready for a knee replacement, the doctors say. My left ankle is affected, too. After the nightmare with my right foot, I am not willing to go through surgery again unless I absolutely can't walk. I am in constant pain, but being handicapped for 18 months was too high a cost for me. The outcome of the outwardly rolling foot affecting the ankle, knee, hip, and back, is a very high price to pay, and has already led to more surgery.

      It feels like there is no help for people with Hallux Rigidus. You're going to pay dearly anyway you look at it, with constant pain, either cause by the pain of Hallux Rigidus itself, and/or the way it throws the rest of your joints off. Your body is going to compensate in some manner, and it's going to cause you misery.

      I am 8 years post-op on the right foot. I really wish a podiatrist/orthopedist/someone would come up with a real fix for this that leaves the patient able to ambulate without pain. What I went through, and the aftermath I've suffered, is not the answer. It is not acceptable. Do not have surgery for fusion of your joint.

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    3. It would be so great if there was a blog for all the people living with Hallux Limitus and could offer their tips on how they deal with this condition. I am looking to maintain an active lifestyle. I am hoping that there are a great number of people who are able to continue to work out and walk/run and are able to be somewhat painfree. Also, to find out what type of shoes that they have found to accommodate the orthotics. Hopefully, some that are somewhat fashionable and not the beige othopedic ones with the velcro closures. It seems everything I have read has been very negative. I am hoping there are those people out there who go day to day without this issue ruling their life!!

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  7. Dear Dr. Blake,
    I was diagnosed with Hallux Limitus 3 months ago. The first doctor who diagnosed this condition, told me to apply Voltaren gel on the joint are 4 times a day and stop wearing high heels. I told him I do not wear high heels except for special occaisions. He told me that it woul continue to get worse and never improve. Also, do not listen to anyone else's opoinion. He said surgery does not work. That was it.
    I went to a second opinion. the next doctor said we are going to try the conservative approch. I just picked up my custom orthotics. I was not given much other information. I wanted help with where to find shoes to wear with the orthotics. Also, can I continue to work out? I like to walk three miles in the morning. Is that ok? He did not seem to have a very definite set of answers for my qustions. I do not want to have the condition get worse by doing the wrong thing.
    I live in the Palm Beach area in Florida. I have been trying to find another doctor to get another opinion from. I would like a referral to the top expert with this condition.
    I have spent hours googling looking for answers. I would greatly appreciate any help you can offer.
    Best regards,
    Karen
    Wellington, Florida

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    1. Karen, I will answer on my blog post for 3/5/12. Hope it helps you. Rich Blake

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  8. Sounds very painful! Is there any age or at any age this disease can happen?

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  9. I have this condition as well. And, it is very painful. My Dr. gave me orthotics and I wore them for a few years to try to stave off a progressively worse joint and surgery. Well, after 5 years I had bone spurs and had only 30% of the cartilage left. I had the surgery to remove the bone spurs and clean up the joints more than 3 months ago. I refused the fusion. I have had nothing but increased pain since. If I walk on that foot, then that joint hurts - worse than ever. I now walk on the outside of my foot and limp. My back is a mess. My Dr. says that fusing is the next step, but I'm not about to have more surgery since the last one only made me worse. What are my choices? He didn't seem too enthusiastic about joint replacement.

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    1. Please see my post for 3/7/12. Dr Rich Blake

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  10. Dr. Blake,
    I have had this condition for over 15 years. I started with orthotics and limited high heel use, then tried anti inflammatory meds, then no heels and limited activity based on irritation. I have also had acupuncture and cold laser with a chiropractor-both very effective. This whole time i have Taken glucosomine chondroitin as well because i figured it couldn't hurt. I'm now 42 and just broke down and had surgery, but just to clean up the joint. My podiatrist was pleased with the surgery and said I had one small spot without cartilage, but for the most part it cleaned up nicely. It has been 8 days and I am feeling like my recovery is going well. I found your website because I was looking for some exercises I can do to help with the recovery. My doctor was going to give me some when I get the stitches out this week, but I would love to have your opinion as well. I really want to get back into walking, running and playing tennis. I really like my doctor(after having seen several doctors over the years) and feel this was the right time for surgery (especially after reading your blogs!) before I was limited to joint replacement or fusion. However he is not requiring physical therapy, just exercises to do on my own. Should I see a physical therapist after my surgery? Thanks so much for putting this information out there!

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  11. Karen Wellington FloridaMarch 27, 2012 at 2:08 PM

    Hi Dr, Blake,
    I have made an appointment to see Dr. Losito next week. I see he is on the staff of the Miami Heat. I am looking forward to meeting him and getting his opinion and suggestions on my Hallux Limitus. I would have never discovered him without your suggestion. I was just using the doctors locally who were referred to me. I appreciate your suggestion.
    Karen

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  12. I've been developing Hallux Limitus for ten years. I'm a keen hillwalker from England and three specialists had recommended that there was nothing for it but a fusion operation (titanium screws). To avoid this, I went to a podiatrist in England who made me orthotics, which relieved the pain for a couple of years. When I went back to him, he also said there was nothing for it but to have an operation. The last surgeon looked an x-ray and said that there was so little cartilage that it was unlikely that a cheilectomy (clean our of the joint and removal of bone spurs) would be enough but he wouldn’t know till he had opened the toe up. If too far gone, a fusion would be inevitable.

    Then I visited the US and discovered Dr Blake. I arranged to go to San Francisco and stayed for 11 days to be sure of having all the treatment I needed before I had to leave the States. I had four appointments, plus an MRI and an x-ray, and he recommended me to Shoes n Feet who specialise in good-looking shoes for people with foot problems.

    No-one previously had suggested an MRI scan, but it showed much more than previous x-rays: there is inflammation in both the metatarsal (foot side of the joint) and phalange (toe side of the joint) bones, plus a small unseen bone spur between toes 1 and 2, and also there is more cartilage than the x-rays had shown. Looking at the MRI, Dr Blake said that I was a long way off needing even a cheilectomy and that we could develop a complete protocol for managing this condition so that I could walk well without pain.

    We now have a plan in place which I can follow while I am back in the UK and which I expect will reduce the bone inflammation and keep it reduced. It involves, in my case, wearing a surgical boot for several weeks to stop all toe bending while the inflammation dies down, along with orthotics made by Dr Blake, specialist taping, specialist stretching exercises, icing, contrast baths and shoes (which don’t look like surgical boots!) to fit the orthotics. Dr Blake spent a lot of time getting the orthotics right and trying them out with different shoes. We also have a procedure for when I do a lot of walking and the joint flares up again.

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    1. I had the wonderful pleasure of meeting and trying to help Lizzie. She so honored me by spending the necessary time in San Francisco to make sure we dotted every i and crossed every t. She left with 3 pairs of orthotics for different functions/shoe gear. She is an excellent taper. I took awhile perfecting her Morton's extension which had to be rigid. It cost around $700 US dollars total to get the imaging I needed since she needed to be self pay. The next 3 months are easy since she has a removable boot (bought online) to completely limit the toe from bending. Her weaning out of the boot, while maintaining a pain free environment, may be slightly more difficult. Thank you Lizzie for adding more excitement to my day, and being the very special person you are!! I miss you already. Dr Rich Blake

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  13. I am an ex-college cross country runner, who now enjoys running marathons, half marathons, trail races, whenever I can. I'm 28, and after one long race a few weeks ago with several big hills, I found myself having to limp because of the pain my big toe joint. The pain has definitely improved over the last two weeks, but its . My toe has never quite been as stiff as it is now, but its been very stiff since my high school soccer days. An xray showed bone spurs and all of the normal stuff. Before this race, I've had zero pain in this joint. Both doctors told me that running is a thing of the past. I'll be totally crushed if this is true... Were there any physical conditions present in your runner patient that allowed him to keep going? or did he just do a great job managing it with conservative treatment?

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  14. Dr. Blake,
    I have been recommended surgery for this condition. As long as I have good shoes on, my toe does not bother me significantly. However, I do experience some pretty severe pain at times if I've overdone it or ran around barefooted. I'm 46 and active with three young children, and the doctor recommends surgery before the condition progresses to a point of having the joint fused. I'm hesitant, not knowing how long it will be before the joint requires that. If it's going to be 30 years, I'll put it off. I guess my question is, when do you make the determination surgery is necessar? Is there truly a benefit to correcting this condition early on while things aren't so bad, or should a person wait till things grow far worse?

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  15. This is a great question and I hope you will be able to read my response. What you are talking about is preventative surgery? Surgery to prevent other surgery or delay other surgery. I suppose that there are a few cases of this that make sense, but not big toe joint surgery. Any surgery on the big toe joint will weaken and stiffen it. After surgery you are more reliant on orthotics, taping, icing, physical therapy, etc. You job now is to see what you can do to minimize/prevent the severe pain episodes. That is what will save your joint. Some, level 0-2, pain is par for the course with an arthritic joint. It is the pain from the low grade inflammation. Higher levels of pain may mean you are breaking down the joint. If you have surgery, it will not be a good joint, and you will have even more restrictions. There is no study that I know documenting the percentage of patients with an arthritic big toe, or knee, or hip, joint that go on to surgery. Do not do surgery to slow down the arthritis, since I am not sure that can happen. Have surgery if you can not control the soreness and it impacts your life (since we only have one of those for all I know). If I decided to have surgery for this, I would get a baseline MRI, and then spend 1 year rehabilitating the joint. My blog is full of information on what to do to help a painful joint. If you do not succeed, have the surgery with no regrets. But, you may get a lot better. My office has probably 500 plus patients with this problem in all different points of the progression of the disease. They have surgery only when the disability of the problem outweighs the disability and risks of the surgery. Please email again with any other comments. DrRichBlake

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  16. Hi Dr. Blake,
    I am so glad that I found this site! I have been diagnosed with Hallux Litimus - very mild with a small spur just beginning to develop on the top of the joint. I didn't even notice stiffness in the joint until the dr. pointed it out to me. I simply noticed the bump when I tried on a pair of heeled sandals with a strap across the bump. So I went to have it checked out and was diagnosed. The doctor suggested surgery "at some point, but not yet." I was pretty disappointed with the suggestion because it seemed so vague, but that's for another day. My real question is this: I've read that Platelet-Rich Plasma injections can help with certain arthritic joints and have been replacing cortisone injections recently. . . is there any evidence that PRP could work for Hallux Litimus? At this point, I'd be happy with just maintaining my current condition and not allowing it to progress or worsen. I currently only have pain when wearing shoes that touch the bump, and occasional aching/stiffness, but no real pain. Thanks for any info you could give me on PRP in the big toe.
    Krista Nutter
    Cincinnati, OH

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    1. Krista, I answered this great email on my blog last night 8-9-12. Hope it is helpful to you. I changed your name for privacy since there is no connection with this post. Rich

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    2. Here is a copy of the post> Rich


      Early Signs of Hallux Limitus: Email Advice
      Posted: 09 Aug 2012 10:18 PM PDT
      Hi Dr. Blake,
      I am so glad that I found this site! I have been diagnosed with Hallux Limitus - very mild with a small spur just beginning to develop on the top of the joint. I didn't even notice stiffness in the joint until the dr. pointed it out to me.
      Dr Blake's comment: Hallux Limitus means limitation of joint motion across the big toe joint. I find that the average patient understands when there is pain in the joint, but are not aware of the subtle reductions in lose of motion. Hallux Limitus is less than 60 degrees of motion, Hallux Rigidus less than 30 degrees. Normal Big Toe Joint Dorsiflexion is 80 to 90 degrees. Walking needs approximately 60 degrees, so limitus is less than this amount.

      I simply noticed the bump when I tried on a pair of heeled sandals with a strap across the bump. So I went to have it checked out and was diagnosed. The doctor suggested surgery "at some point, but not yet."
      Dr Blake's comment: Golden Rule of Foot: The disability from surgery should be equal to the disability of the problem before surgery. What does that really mean? You must be quite limited in your life to undergo an elective surgery that hopefully temporarily is quite restrictive to your life. I definitely do not see that in your life. And I do not buy into preventative surgery, surgery to prevent the joint from getting worse, since all surgeries weaken joints, and have the potential of permanent disability via complications. Listen to your body. When the treatment option is a surprise to you, it is probably not right at that time.

      I was pretty disappointed with the suggestion because it seemed so vague, but that's for another day. My real question is this: I've read that Platelet-Rich Plasma injections can help with certain arthritic joints and have been replacing cortisone injections recently. . . is there any evidence that PRP could work for Hallux Limitus?
      Dr Blake's comment: I have no experience with PRP, but it makes sense in situations of chronic tears ligaments or tendons. It may be important with arthritic joints, but I am just not convinced yet.

      At this point, I'd be happy with just maintaining my current condition and not allowing it to progress or worsen. I currently only have pain when wearing shoes that touch the bump, and occasional aching/stiffness, but no real pain. Thanks for any info you could give me on PRP in the big toe.
      Cristi


      Hey Cristi, To me the doctor had no place to bring up surgery in this scenario. What is the purpose in a non painful joint? I have so many patients I have treated for the last 30 years who have a bump, have some limitation in motion, but that is all. You need to see someone who is an expert in conservative care of Hallux Limitus, who can examine you, and decide what conservative measures you should do to help the joint. If you read all of the posts on Hallux Limitus, they mainly deal with reducing pain. But you have no pain. For now, do not worry, find shoes that make you feel comfortable. Read a little, but not too much, on Hallux Limitus. And Listen to your Body! Hope this helps. Rich

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  17. Hi, Dr. Blake--I am a 34 year old veterinarian and triathlete :) I know I am hard on my feet. I was diagnosed with Hallux Limitus in the left foot last year, only occasional mild pain. Over the past year, the pain has increased to pain while walking, but not running or cycling. NSAIDS and orthotics have been prescribed, as well as felt padding/kinetic wedges under my Superfeet and under the insert of my Newtons. The sports medicine doctor and the podiatrists have said I can keep running--it is my "happy pill" and how I deal with stress in my life. I would hate to give it up. Any general tips? I'm starting to experience left lateral knee pain now in the same leg, so I'm obviously compensating. When/do I give up running? When/do I have a surgery? Do you have any recommendations for podiatrists or orthopedic surgeons in the Raleigh/Fayetteville North Carolina area? Thanks so much for your help--it's obvious that you love what you do :)
    Shelly
    swhitehu@vt.edu

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  18. If you are getting lateral knee pain, the shoes and inserts are letting you drift out too far. Please have them adjusted to be more centered. If you listen to your body, it typically tells you what you can or can not do. Definitely, if you can figure out the knee pain, you can keep running. Learn how to spica tape also, that can help you run more centered. Experiment with shoes for walking, perhaps with custom orthotics, that can minimize those symptoms. Avoid cortisone shots unless you are ready for surgery. Surgery should be done when you are adequately disabled by this, which does not sound like it now. Check the AAPSM website for a sports minded podiatrist in your area. Rich Good Luck

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  19. Dr. Blake,
    I had surgery on both of my big toes in Feb. 2009. It seems to be a hereditary issue since my brother had the same surgery a few years earlier. My father and grandmother had arthritis here too. I had cracked the toe while running for only 3 years. I cracked the bone on my left foot and it also had numerous bone spurs. Since the swelling did not go down after 6 weeks, surgery was performed. I had them xray the right foot, which also had spurs, so I opted to have both of them done. Yes, it was a painful surgery. I got a general and not a local so when I woke up I was in terrible pain. I blame the Dr. on that one.
    In 2010, a year later, after training for a triathlon I developed Plantar Faciitis. It came on very slow but by 201i and now 2012 it has stopped me dead in my tracks. I have had pain for two years. I finally got an xray that showed a heel spur also. I have have tried everything, constant exercises, scraping, orthodics (OTC)and have stopped running. Nothing helps.
    Question? Did my surgery have anything to do with this issue?
    I am afraid of cortizone shots. Should I have an MRI?
    I am 59 yrs. old. Running was my new hobby. It kept me off of antidepressant after my husbands death in 2006.
    What do you suggest?
    Pam

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  20. Pam, I am answering tonight on my blog 11/25/12. Sure hope it helps you. Rich Blake

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  21. I have hallux rigidis, bunions and bone spurs. I've seen 4 different doctors. 2 said it is the worst case they've ever seen. I barely have any cartilage left. But I walk on the outsides of my feet so I'm not in pain for every step. I also play tennis and can deal with the pain when I play but my feet hurt afterwards. I have to wear super wide shoes - New Balance extra wide. I can't wear heels. The first doc recommended implant surgery. The second and third recommended Decompression Osteotomy. The fourth recommended fusion surgery. I"m so confused. I live in Marin County, CA right over the Golden Gate Bridge from San Francisco. Can you recommend any doctors in my area? What do you think I should do?

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    1. Julie actually made an appt and we are going to see how it goes. She is by far not the worst case ever, so I wonder why she was told that. She knew none of the basic treatments, and I started her on a progressive plan of attack. Rich Blake

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  22. Dr. Blake,
    I am only commenting on your blog because i want to simply say thank you. Why? Well, you seem to be one of the very few physicians willing to comment on hallux lim and rig without a pre established agenda. No offense, but I went to see an orthopedic and two podiatrists each of which were selling me a surgery and had me under Anesthesia before the xrays lights went off. neither suggested any of your conservative approaches before surgery was offered. I found that terribly odd. My pain was bad but i felt there should have been something else said/suggested. After reading your blog and your YouTube videos i learned more about limitus (which i realize i have) and ways to calm the joint down etc. as you said, "it should be treated as a sore joint. Nothing More."
    I have full Motion in the joint with the small "bump" on the big toe but inflammation after running and power walking etc, Stiffness in early mornings etc. But Spica taping helps as well as whatever else i learn from your info. I think my initial battle was accepting that my body was actually getting older and that's the hardest thing for me. Truly. I'm 39. If/when my condition getS to an unmanageable/intolerable point I'll fly to sf from Chicago and give you a visit without hesitation. Meantime I'll continue following your blog and implementing the advice. Again, thanks.

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  23. Dr Blake,

    I love how you promote the conservation approach and I desperately want to find a doctor in my area who is highly regarded and thinks optimistically like you do without suggesting surgery right off the bat. Do you have any recommendations for doctors in the Cleveland/Akron area? Thank you!

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  24. The 2 doctors I know in Ohio are Dr Stanley Beekman in Cleveland and Dr Pamela Sisney in Cincinati. They would at least know who are good in your area. Hope this helps, and thanks for the comment. Rich

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  25. Male, early 40s and I take exception with opinions above steering people away from certain treatment. I started in orthotics for a while, then bilateral chielectomy in 1999 for Hallux Limitus, eventually progressed to minor Hallux Rigidus. Again, chielectomy got me by for 2 years before little was left for joint space, along with arthritic bone surfaces.

    Tried arthroplasty on left instead of fusion. It failed due to quick return to arthritic bone surface that shredded the tissue. Fused shortly after, then once that was stable enough, fused the right at the end of 2012.

    This year I've had a sesamoid removed in the right, opted to increase the angle of the fusion in left due to some hip/back pain and general discomfort of the toe in shoes. I'm weaning out of the walking boot now, but showing signs of sesamoiditis already. My guess is I'll just have that removed and not drag out the process any further.


    I've had 9 surgeries, and I will state with extreme confidence that if you take the usual 7-10 initial days of recovery IN BED with foot up, you'll be far better off. Toughing it out or playing hero by going back to work in 3 days, slows healing and greatly increases risk of infection and injury of vulnerable foot... won't fool your doc at all either. They know when you push it.

    I was a U.S. Marine... I can push myself physically and mentally. But I know enough NOT to push. What's the benefit of pushing? None... except maybe to your employer. It's NEVER acceptable for your health to be less than top priority for you and even your employer when you end up in surgery again... less productivity long-term, etc. Of the 7 my current surgeon has done, he called me out on #4. I went back to work at 6 days, 3 days sooner than any other and he knew it before I said a word.

    I have no hesitation about surgery if needed. I have a fantastic surgeon, ask every question I can think of and accept answers I may not want to hear. Consider your situation honestly and do what is recommended by the doctors. The recommendations aren't guesswork.

    I suggest the opposite of a gal above. DO consider fusion or other procedures, but only a good fit for your condition, your surgeon's preferred course and all post-op aspects of the process. Ask about what's next after surgery. What option are if something doesn't go as planned. It can and does happen, and having a plan you and your doc agree upon is vital. Don't focus on future problems, but do talk about the possibility. Non-union of a fusion after you went out golfing on day 4 is on you and if you have a plan for complications, everyone moves forward. My surgeon actually had such a patient. Next initial post-op visit, I walked in using a 3-iron as a mock cane. :)

    Oh, and shoes are often a question here, as well. For me, hands-down, New Balance with plenty of width. Do not skimp on width! You'll get used to and treasure it very quickly. Even then, the exact same model/size can differ between pairs. Finding what works consistently does take time, and likely won't be a $29 pair of cheapo shoes. Pain relief is worth time and money for me, though.

    The local New Balance store lets me mix and match from boxes of same size/model and gives me 7 days to walk in them because they know I'll be back next time. Even a 1/8" tilt difference due to slight tweak during manufacturing of two otherwise identical shoes makes all the difference in knee/hip/back soreness. As shoes age, they stretch in different places, as well. Do not discount this aspect of your treatment and recovery... you do so at your peril.

    I'm a lurker, but a fan, Dr. Blake... keep up the great work, and your participation in discussions here is valued far more than you realize! Without it, the site is just a place for you to opine and others to talk about you, usually in the negative, benefiting nobody. Because of your willingness to be involved, I have sent two your way, one a happy cured patient, the other currnet and they are very pleased, as well.

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    1. Thank you for all the great wisdom. This is wisdom I can not give since I have not personally had these surgeries. I am going to place your thoughts also as a separate post on my blog. Rich

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  26. Hello Dr. Blake, I am 53 years old, diagnosed with severe (late stage 3) Hallux Rigidus 3 years ago. Surgery to clean up the joint and get rid of the bone spurs was recommended. I opted to not do it. I was once an avid runner, x-country skier, horseback rider, but now can do none of these things. Can't wear heels (i.e., riding boots) or any kind of constricting shoes. No upward mobility on the toe at all. I walk on the outside of the foot. Lots of pain. Chiropractic helped for a short period. I also fell off a horse and broke my sacrum six years ago, and the two things--the HR and the fracture, have sent me into a cascade of pain--quads atrophied, arches fell, both Achilles tendons blown, hip pain, neck and shoulder pain, mid-back/rib pain...you get the picture. I am working with my GP on many of these issues, but the HR needs a specialist, and I was not too impressed with the orthopedic surgeon I worked with here in Idaho. I am a Californian, will be moving back to CA next year, and could easily come in to consult with you. Do you have surgeons in the area you can refer me to if that seems the best course of action? Thanks for any help! Barbara Moritsch

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  27. Definitely, Dr Remy Ardizzone in our office is skilled at all of the types of procedures. We would get a new MRI and look at the picture. I ask my patients to get several opinions and then I help them make their decision. I look forward to helping you. Rich

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    1. Thank you! I will be in touch.

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  28. Dr. Blake, can you recommend a doctor in Southern New Jersey? thank you.

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    1. Sorry for the delay!! The 2 doctors I know the best are Richard Braver in Englewood, NJ, 201-569-7672 and James Ricketti in Hamilton 609-587-1674. Hope this helps you. Rich Blake

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  29. Dear Dr. Blake. Would you please recommend a good doctor in New York? I am in great pain because of Hallux Rig in both toes. And it 's deteriorating rather rapidly, just in 2 years. The doctor recommended surgery, but I would rather try everything else first. Many thanks, respectfully.

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    1. Thanks for the email and good luck. My top 3 in no order are Karen Langone, David Davidson, and Thomas Connenello. You can find them through the aapsm.org website. If they are too far, they may be able to recommend someone closer. Rich

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  30. Hey Doc,

    As many have said....your/this blog is so incredibly valuable. And makes me not feel like I'm the only one with this problem. Can you suggest anyone in the Wisconsin . I live in Green Bay but can travel to Milwaukee and even Chicago, if needed. Thanks. I am looking for someone to really work with me on orthotics.

    With gratitude.
    Jo Anna

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    1. Jo Anna, go to the AAPSM website. There is great potential in this list. Let me know if you find someone. Rich

      http://www.aapsm.org/members.html#wi

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  31. I am 2 weeks post opt rom having a cheilectomy done on left foot. I am pretty pleased with how it is going and am in a soft shoe most of the time. 13 staples taken out 3 days ago and this seems to be quite sensitive where these were taken out and healing is slow. Hoping in 2 weeks I have greatly improved by then. Less is more for this type of problem and my doctor feels a fusion is last option to consider. I'm 49 year old female very active and a runner so will keep you posted on my recovery. My hallux rigidus was quite bad and it was time to do something about it. Good luck everyone and if I can be of any help let me know.

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    1. Thank you for the comment. I will place this on its own post for comments. Go to Cheilectomy post op in my labels to access. Dr Rich Blake

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  33. Hi, can you recommend a good surgeon in the Boston area? I would like to consult a surgeon to explore the options. I am 62 years old and have Hallux Rigidus, with no cartilage left in my MTP joint. This has been progressing for 40 years, due to 20 years as a classical ballet dancer. I have custom orthotics and wear only shoes with enough room in the toe box, but it has reached the point of constant pain. I just discovered your site today, though, and I am trying taping the joint. I can't believe neither the podiatrist nor the orthopedist suggested this! I am hoping it gets me through a vacation of light hiking! If it does, maybe I just wear tape for the rest of my life. Thanks for the great site! So much information! Clicking on the Donate button now!--Libby

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  34. Dr. Blake,
    Not sure you will see this, but I saw the podiatrist for heel pain that was exacerbated by an *K run, as will as some burning discomfort on the back of my ankle where the Achilles tendon is. He proceeded to tell me that I need an osteotomy and, if that didn't work, an artificial joint in my great toe. The toe clearly is arthriitc, but the only problem I have is sometimes fitting shoes (dress). I can do all 26 Bikram yoga poses with ease---I have never had trouble bending my toe. I do have to concentrate on pressing the toe down, a situation I have attributed to the following: leg length discrepancy, and some neurologic deficit in the right foot from some spinal impingement (spina bifida occulta, scoliosis, spondylolisthesis, etc., so on). The podiatrist wasn't the least bit interested in this and when I asked for an orthotic, he said that would make my pain worse.
    Bottom line: heel pain made worse by running a longer (for me) distance, soreness at the back of my heel, no toe pain. Am I getting good advice?

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    1. Sorry for my delay. Of course you are not getting good advice!! Hopefully you have run away from that guy. We all need docs to understand us, take time to listen, not quick to cut. Try to get another referral in the area. Rich

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  35. Hi Dr. Blake,
    I just found your site today, and have read all your information on Hallux Rigidus. I am a 59 year old active female and have been diagnosed with Hallux Rigidus stage 3 in my right great toe and stage 2 on the left great toe (arthritis). The podiatrist I went to recommends a fusion on the right great toe and a synthetic Cartiva implant on the left great toe. I am seeing an orthopedic surgeon specializing in the foot and ankle tomorrow for a second opinion. I was leaning toward getting the surgery, but after reading about it more, I am feeling reluctant. My pain comes and goes. It was flared up recently (probably from walking barefoot on the beach), which caused me to go back to the DPM (I had gone to him 7 years ago when this all started, and insurance prevented me from pursuing it over the last 7 years). I’ve been managing it by wearing custom orthotics and wearing shoes that don’t irritate it (which is a very limited selection of shoes).

    I really like your approach. Since I live so far from you, I am wondering if you can recommend a doctor in the Philadelphia, Pennsylvania area. I live in the western suburbs of Philadelphia (Chester County, west of Valley Forge). I would be able to travel to Philadelphia if you don’t know anyone closer to me.

    Thank you!




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    1. Thanks for the comments. Yes, I am sure there are tons of stuff to do before surgery, which can always be done. Here is a list of like minded docs, particularly Gary Gordon or Palamarchuk. Rich

      http://www.aapsm.org/members-northeast.html

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  36. I agree there is very limited information about people living with an untreated condition and nonexistent resources and tips to hide the problem.

    The problem of finding comfortable wingtip shoes for men without looking like a cripple is an impossible challenge.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.