Hi Dr. Blake,
Wednesday, June 20, 2012
Hallux Limitus: Post Op Advice
Hello Dr. Blake,
My name is Julie and I came across your site while researching hallux limitus surgery recovery.
I'm a very active 48-year-old (with a 4-year-old daughter) and decided to have the procedure with my podiatric surgeon on April 27 after dealing with the disorder for three years and having tried everything—orthotics, chiropractic, acupuncture, you name it.
I think the procedure went well, and though I know you can't comment on my case specifically, I'm wondering if given your experience in this area, if you can give me a sense of what you've seen with patients who don't show signs of immediate improvement (given normal healing time from the procedure). It's now 7 weeks out for me, and though I seem to have a bit more flexion than I did before, the pain is worse than it was before the surgery. My doctor was hoping to see more progress at my second post-op checkup two weeks ago, but she says to remain optimistic. I'm starting physical therapy next week.
I get the sense from what I've read that by this point, the patients for whom this surgery is going to "work" have less pain than before the surgery, but pain greater than before the surgery at this point is a sign that the procedure didn't "work." (Using the word "work" very loosely here, of course).
Again, I know you can't comment specifically. I'm just hoping you might have "anecdotal" input that could help me figure out the best way to move forward (I'm considering a cortisone injection after the 3-month mark if it's still painful). I want to have the best chance of getting the relief I had hoped for from the procedure.
Thanks so much in advance for any insights you could share.
Dr Blake's comment:
Thank you for emailing, and, of course, there are a hundred questions I could ask you. Please email what type of surgery they performed and I will add to this email over time. First of all, all these surgeries other than fusion create a lot of raw sensitive bone which takes 6 months to 2 years (or more) to heal. You must protect this new born baby of a joint, and avoid painful activities. The raw bone is very sensitive, and slowly gets less sensitive. The things in your court to help are controlling the inflammation (icing and contrast baths), avoiding bending the toe (stiff soled shoes, orthotics, carbon graphite plates, spica taping, removable boots, etc), and time. I don't consider an MRI for 6 months, but like to wait 1 year. Surgeons like surgery, shots, and casts. Try to create a pain free environment, and then gradually month by month increase your activity. 70-80% of these surgeries work great, but you can not judge the results during the first 6 months well. Avoid cortisone with a passion--at least for the first year, unless you are not functional day to day. First priority--create that pain free environment so that you can function day to day with 0 to 2 pain level. Hope this helps with focusing on where you are at. Rich
Hi Dr. Blake,
Hi Dr. Blake,
Thanks so much for your quick response on your blog--it made me feel so much better (I've been very demoralized about this whole thing, which I know doesn't help with healing).
To answer your main question: The surgery I had on 4/27 was a standard cheilectomy (no osteotomy).
I have my first physical therapy appointment next Wednesday and haven't yet gotten the Dynasplint prescribed (don't even know what that is yet).
I think my main question to you based on your blog response is regarding motion: after the boot came off, my doctor instructed me to manually move my toe up and down at that main joint several times throughout the day to help increase ROM. I'm wondering how that type of joint movement squares with your advice to keep the toe mobilized. Also, more broadly: wondering how walking in regular shoes (or barefoot) is different from moving the toe manually.
Since I'm lucky enough to have you close by, I'm thinking I might make an appointment to see you after I reach my 3-month mark and have a post-surgery x-ray taken.
Thank you again in advance for all of your help. It's such an inspiration to meet someone who is so obviously passionate about his work (and helping others!).
Dr Blake's comment:
The standard cheilectomy (basically shaving off all of the bone spurs, but leaving some damaged cartilage) is definitely what I would try first with painful Hallux Rigidus. Your two limitations to bending the joint is raw exposed bone and the ligaments that surround the joint can get stuck down to the new bleeding bone (called adhesive capsulitis). You will gradually create motion back into the joint with walking, then running activities, but first with self mobilization (I have a video on this and the Physical Therapist can review with you to make sure you are getting it right). Any range of motion device or technique that causes pain while doing will probably make you tighter in the long run. The Dynasplint has been around, but I am not familiar with it enough to comment. Please have the physical therapist measure the joint range of motion (dorsiflexion and plantar flexion) at every visit, and especially after 6 Dynasplint sessions, to document if the range of motion is improving or not. It is crucial that the same physical therapist measure the motion each time. Moving the toe manually will be best with the 4 directions taught in the self mob video. Walking will never get the plantar flexion range of motion better than the exercises. Too many things can make the dorsiflexion range of motion less if they irritate and produce pain. So, get back to thinking about the pain free environment we need to achieve. Remember your joint will help teach you what is good and bad for it better than any doctor, blogger, or other general rules being applied. Hope this helps. Rich