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Monday, October 17, 2011

Hallux Limitus/Rigidus: Email Advice

Hi Dr. Blake,


I have been feverishly searching the internet looking for answers for pain relief from hallux limitus/rigidus (far worse in the left foot, but also present in the right).
Dr Blake's Comment: Hallux Limitus/Rigidus technically means a restriction of motion across the most important joint in your foot---the big toe joint, aka first metatarsophalangeal joint. This limitation can be functional, structural, or a combination. Functional limitations of the joint can be due to over pronation which jams the joint down into the ground as the arch collapses. Structional limitations imply mild (limitus) or moderate/severe (rigidus) arthritis.

I came across your site which seemed to be the most informative between your blog posts and replies to comments and videos. I would love to come out to San Francisco to see you; however, I live in Virginia, so I'm hoping you can recommend someone closer to home.
Dr Blake's Comment: Three of my very favorite podiatrists out there are Ayne Furman, Steve Pribut, and Paul Taylor. Go to the website of the American Academy of Podiatric Sports Medicine (www.aapsm.org) for their info. They are all great caring podiatrists.

 I have been struggling with this issue for over 2 years, and recently the pain has become an on-going issue rather than flairs here and there. I have attached my x-rays if you would like to take a look at them. So far I have been to 3 podiatrists and not happy with any of them for various reasons.
Dr Blake's comment: I did review the xrays which revealed little sign of any arthritis (great news!!)


The first doc was probably the most helpful but his personality and that of his nurse (spouse) and office staff was just off.
Dr Blake's comment: Unfortunately those chosen for medicine, can be brillant (not me) but their personalities remind me of fish out of water. They have had to sell their soul at a young age to get into medicine, and never developed good social skills (I am sort of like this!!) Doc Martin on TV is like this, and I am surrounded by Doc Martins on a daily basis. Medicine is just too hard to get into and stay in. Not sure what the answer, but we need our docs to keep going personality-flawed or not!!

That was over 2 years ago when the pain first started. He actually assessed my gait along with taking x-rays and doing a physical exam. He made me custom orthotics for dress shoes, of which I found 1 suitable pair that I could actually wear without them killing my feet after searching tirelessly for months.
Dr Blake's comment: Hallux Limitus/Rigidus is not an orthotic issue generally. Orthotics for dress shoes normally stop before the ball of the foot and are designed to increase motion across the ball of the foot. If this is the sore joint, forget it. It probably has to be one shoe that has the right amount of inflexibility in the front of the foot, and the exact right amount of heel lift, and the exact amount of forefoot cushion to work. Zappos is great, but sometimes, miracles are needed for a dress orthotic to work. Now, if the dress orthotic has a built in ball of the foot stiffener to limit motion, it could work better. I said could didn't I.

 I have seen 2 other docs in the past 4 weeks.
Dr Blake's comment: It is wonderful to start getting some opinions, but the dilemma everyone has, and the reason for your email, who will help you sort out the different information. Sometimes, what seems to be different is actually the same info packaged differently. Can be very confusing!! Don't forget about your PCP or a good sports medicine PT to help sort this out. In my ideal world, podiatrists would do a better job being the PCP for feet, allowing room for second opinions, and even another podiatrist making orthotics, or doing surgery, if better qualified. Too much ego out there.

 The first gave me a medrol dose pack for the inflammation, which after a few days made me feel like I had the never ending flu, aching from head to toe (including swelling and pain in my ankle where I apparently have an old fracture from 20 years ago - doc #2 pointed it out the bone spurs on my x-rays. It never bothered me other than the annoying popping and cracking sounds, but all of a sudden I'm in constant pain. Is it conincidence it started hurting while I was on the prednisone due to compensation from the big toe pain, or something to do with the prednisone causing me pain all over my body?)
Dr Blake's comment: Swelling in any area can function as a cast limiting painful motion. As swelling is pulled from that area, and the joint involved moves more, pain from arthritis/bone spurs can crop up. Hopefully, within a week or two all will re-equalize in your body. Prednisone is also slightly unpredictable. It should reduce swelling and make you more wired. I have more then my share of patients that the swelling gets worse, and they are knocked out. Sometimes, life is unpredictable, but with Prednisone, this happens quite frequently. And it pisses me off, pardon my French.



. When I showed him a pair of Dansko clogs that I had purchased for his opinion, he took a look at them in the box and said they were good.
Dr Blake's comment: That breaks all the secret rules of podiatrists. You can not tell how a shoe or insert will function unless you watch it perform.


 I told him of my shoe shopping frustrations, and he basically said I was going to have to just keep on shopping until I found something that was comfortable to me.
Dr Blake's comment: Have you found shoes that feel good without the orthotics? If you could only go shopping with Kinesio Spica Taping and 1/8th inch adhesive felt Morton's or Reverse Morton's Pads (whichever feels the best) I bet you would have a better experience. See other blog posts regarding these.

 I told the second doc about the issues with the medrol dose pack and that I got no relief from the pain as well as the new pain in on top of my foot/ankle. He built up the arches of my dress shoe orthotics and sold me a pair  of orthotics for tennis shoes to which he did the same. After 2 weeks, still no relief. He said the Danskos were too stiff and my current dress shoe was too flimsy, and I needed to find a happy medium (but still no good advice on what to look for).
Dr Blake's comment: It is overwhelming, since you are trying to fit an orthotic, and make your foot more comfortable. I would start again with spica taping at least with no padding, unless this kind doc could show you how. Start icing the front of your ankle 15 minutes three times per day to calm down the irritation, and at the same time ice the top of both big toe joints.


 I followed up with him 2 weeks later (Monday) with intense pain in my arches and continued pain from the hallux rigidus, swollen/painful foot from old fracture.
Dr Blake's comment: Again, this is not primarily an orthotic issue, so I would cease and dissist (sp?) until further notice. The higher the arch, the more pressure in the front of your ankle.

 He convinced me to get a cortisone injection for the hallux rigidus pain. I have at home for the past 2 1/2 days unable to do much of anything other than ice it and rest. I know people can have more pain for several days after getting a cortisone shot.
Dr Blake's comment: 1 cortisone shot will not hurt you, but I would minimize them. They can take 3 to 7 days to work, and then mask pain for up to 9 months.

 My main concern is that I keep getting these sharp stabbing pains on the bottom of my foot intermittently when I walk. It it almost a pins and needles type sensation, but in a very small area at one time rather than the whole foot). I tried to call the doctor's office today to get their opinion; however, my doctor and his nurse were out of the office today, and the secretary didn't feel like my issue was that urgent to bother the other nurse in the office.
Dr Blake's comment: Where is the pins and needles? If it is post injection, the injection probably just stimulated one the nerves running alongside the joint. It should pass. Nerve pain however, and numbness/burning/tingling are part of the symptoms patients get when the nerves are upset, can gradually develop when their is chronic pain. Could end up needing a nerve guy (neurologist/physiatrist) to calm the nerves down.



PLEASE HELP!!! I'm desperate for pain relief, answers, and suggestions on how to get my life back. Thank you in advance!

In Good Health,

Emily

Emily, I hope some of my comments helped. Since it took me 3 weeks to respond to your email due to my vacation in Hawaii (when can I go again???), give me an update to answer my questions and tell me your thoughts on taping, padding, etc.

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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.