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Thursday, January 5, 2012

Hallux Limitus Surgery: Comments on One Doctor's Protocol

Received this email from a patient Jeff I had just. He is deciding on surgery for his Hallux Rigidus. There are many great points brought out in this correspondence. All of my comments are in red.


Dear Dr. Blake,


I so appreciate the opportunity to meet with you and discuss options for my great right toe.  As we discussed, I was scheduled for a Cheilectomy (joint clean out procedure) with a good podiatrist on January 20, 2012.  After our meeting, I emailed the doctor and told him I wanted to postpone surgery.  He was very understanding and said I should only do surgery when I was ready.  I wrote him again and asked him if he would order an MRI, so that both you and he could have more detailed information on my toe. 
 
Dr Blake's comment: I told Jeff that an MRI can reveal the extent of injury to the joint much better than X-rays and I would want them to be part of my pre-surgical workup if it was my toe. 

Here is part of his response that addresses the MRI:


'Hi Jeff,

I have no idea why your doctor suggested an MRI. We use MRI to evaluate muscles, tendons and specific anatomy, like soft tissue masses. Occasionally, we will order one if we have tried everything else and are puzzled. Your problem, Hallux Ridigus, is straight forward. You have arthritis in your 1st Metatarsophalangeal joint. An MRI is not going to give any additional information in your case. Although it would go to your health plan, it is completely unnecessary! 

MRI of Hallux Rigidus patient with surprise sesamoid injury and marked bone inflammation on the plantar surface making it difficult to walk.


Dr Blake's comment: This doctor just has not used MRIs for this problem and therefore does not know where they fit in to the process. There is nothing wrong with this, but I would say MRIs can help categorize the damage in the joint by intensity and location, can show other injuries that  could co-exist with the Hallux Rigidus like sesamoid arthritis. Every Hallux Rigidus is not the same, and could require different approaches. At least in 2012, where MRIs are now a proven entity, some vital information can come from it that could effect the management of the post operative period. 
I am listing our standard approach for treatment for Hallux Rigidus:

X-rays show significant arthritis to your great toe joint Arthritis is a progressive loss of cartilage and results in stiffness and pain. 
The pain from the arthritis can often be effectively treated with the following: 

1. Period of rest from any aggravating activities: e.g. Long walks, jogging, hills, stairs. Low impact exercises would allow for consistent cardiovascular exercises without exacerbating foot pain. Such exercises include stationary or regular biking, swimming, water aerobics, circuit-training weight lifting. 
2. Wear shoes with good motion control: 
3. Graphite plate inserts help reduce bending at the big toe joint. These can be purchased at Shoes N Feet in San Francisco or other Shoe stores.
4. Occasional cortisone injection is probably the most effective non-surgical means of reducing pain. Relief is temporary but may last 2 months or more. Cortisone injections cannot be done indefinitely but several done 4-6 months apart, as needed, are safe to do.
5. If non-surgical treatment fails to adequately address the pain, surgery will likely be required. 

Dr Blake's comment: This is a good starting point, although I have never had the graphite plates help (but they are worth a try!). Since Hallux Rigidus means cartilage breakdown, avoid cortisone shots unless you are already for surgery, not if you want to avoid surgery. Cortisone can temporary help the joint, but by masking pain, can speed up the breakdown of the joint. Use cautiously. In all my years of treating Hallux Rigidus symptoms, whether to avoid surgery or after surgery, the following treatment modalities have proven crucial for patients and should be tried pre-op (you may get lucky and avoid surgery):

  1. Functional Foot Orthotics to change the gait pattern and weight bearing across the joint.They can also be used to limit joint motion with Morton's Extensions.
  2. Spica Taping to Limit Joint Motion
  3. Shoes selected to have the right amount of heel lift, forefoot padding, forefoot flexibility or stiffness, toe box room, and upper construction.
  4. Padding to off weight shoe pressure (may vary in different styles of shoes).
  5. Daily icing and/or contrast bathes to reduce inflammation, which decreases the fragileness of the joint.
  6. Physical therapy to initially de-inflame the joint, and then strengthen the foot and work proximally at the core and down to change stressful gait patterns.
  7. Accupuncture to increase circulation for healing, and stimulate the immune system for greater healing.
  8. Removable casts to immobilize the joint for several months or part time on a daily basis while the joint is getting calmed down. 
  9. Glucosamine and other OTC anti-inflammatories.
  10. Flector Patches or diclofenac gel to reduce inflammation.
  11. Activity modifications to avoid irritating the joint for 1 year, but allow as much cardio-vascular fitness possible. 
  12. Too many others to mention (treatment should be tailored to the individual with protocols  designed to create a pain free environment in a general fashion).

A lot of individuals with this foot condition eventually need surgery to decisively treat the painful arthritis. This most often involves fusion (or arthrodesis) of the great toe joint. This is the surgical gold standard to treat big toe joint arthritis in an individual who wishes to remain active. It best and most predictably eliminates the pain from arthritis in a decisive manner and long-term. Counterintuitively, locking the motion in the great toe by surgical fusion, does not interfere with those who want to walk actively or even jog. Only limitations are with going en pointe in ballet dancing, > 2.5 inches of high heeled shoes, and probably sprinting. Sometimes, it can be a bit difficult to get your foot into a tall boot. 

Dr Blake's comments: I have treated 1000s of Hallux Rigidus sufferers and never had to resort to a joint fusion. I have only seen one patient with a joint fusion from another doc and it did not turn out well. It should be the last resort of surgical treatments. The big toe is the most important joint for push off. I just came off the basketball court, I can not imagine doing what I did without the function of the big toe. Maybe it is a better surgery than I realize, but if you can not push through the big toe joint, the push off must be more laterally causing problems related to over supination. That can give you foot, ankle, knee, hip and back problems. Also if you can not roll through your foot, you forward motion is blocked and all the problems related to Sagittal Plane Blockade may occur. So why fuse? Why not try to save the joint, and if surgery is needed, minimize the surgery (even if it has to be redone in a few years). 

Postoperative recovery in most cases involve: 
1. 2 wks of non-weightbearing to the operated foot in a cast 
2. 4 wks of weightbearing in a cast subsequent to the initial non-weightbearing period 
3. 2-4 wks of weightbearing in a orthopedic boot or shoe after the casting period. 

If you're not inclined towards surgery at this time, consider the recommendations above. If you would like a cortisone injection, let us know what days and times would work best for an appointment, and we can have you scheduled with one of the foot and ankle specialists. 

Dr......

So...I'm not going to be able to get an MRI from Kaiser, but have ordered one from Health Diagnostics for January 3rd. 

If you have any additional information about your thoughts on the MRI, and why you think it is helpful,  please feel free to share your thougths, and also let me know should you wish me to share those with my  doctor.

Dr Blake's comments: Jeff, please get the MRI as a self pay ($500 approx). I will see you after to discuss, and then my comments will be available to your doctor. Please look at all of my blog posts on Hallux Rigidus/Limitus, schedule an hour for the upcoming appointment, and we will have more fun.
I look forward to discussing my MRI results with you when they are available.

Thanks for your help, and happy New Year.


Jeff

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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.