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Thursday, October 2, 2014

Hallux Rigidus Post Cheilectomy: Email Advice

Hi Dr. Blake,

I am in tears at finding your blog site; I have been so frustrated and I realize that everything I’ve been told to do with my foot hasn’t helped. 

 My condition is I believe hallux rigidus, although it has been called “arthritis in great toe joint” by my podiatrist.  I am 45 years old, and love to run.  I am in a bit of a crisis with my left foot.  I had a cheilectomy in July of last year (big toe joint cleaning procedure), after suffering for 3 years with a bone spur on the top of my great toe joint.  The podiatrist I saw told me that orthotics would not help, and that surgery was the only option to remove the spur (I have always been very healthy, and never thought to question his prognosis; I know better now). 

 I did not want surgery, but could not walk or run anymore without significant pain.  I had the surgery.  Since that time, I have lived in what feels like a very painful nightmare.  My doctor told me that I would be running again within two weeks post-surgery.  The swelling after surgery was significant, and I knew something wasn’t right, so I requested physical therapy.  The physical therapist had me stretch my toe joint and get back hard into activity and I received very little relief.  At nine months post-surgery, the pain was still limiting, and I feared that my return to jogging and activity was exacerbating the problem, along with the stretching routine, so I requested more physical therapy.  The therapist worked hard on everything in my foot but my great toe joint, saying that I need to stretch it by placing the toe on a wall and bending in for 5 minutes at a time to keep it from stiffening up.  I have been doing that and jogging, and now I feel that I’m in a mess.  The pain is so severe I can barely get from place to place.  My podiatrist said it’s just arthritis and is talking more surgery, after giving me a cortisone injection last week, which didn’t help.  I bought dansko shoes for work, but even they hurt, and I fear that I’ll always be in pain and that I’ll never have any normal function in my foot.

I am a mother of two pre-teen children, just graduated from grad school and in August started my dream job of teaching, and I feel like I’m at square one in treating my foot pain.  I desperately need help to know what to do to first.  I have an appointment to see an orthopedic surgeon soon, but I feel I need to start somewhere now.  Where should I start?  I know now that “hitting it hard” physically has exacerbated my symptoms.  I will switch to biking, yoga, and swimming.  I can’t walk one step without pain, so should I try taping, inserts, etc., as well?  I feel that I’m at square one with very little guidance and no one to turn to. 

I would very much appreciate advice on where to start…insoles? More physical therapy? Taping?  The pain is excruciating when I walk, so I know to take it easy, but for how long and in what ways?

Thank you so much!

Gerry (name changed)

Dr Blake's response:
     Thank you so very much for the email. First of all, for the next 3 years, you need to create as much of a pain free environment as you can, and as quickly as you can. Please go into a removable boot, with EvenUp for the other side. This should be combined with icing 3 times a day to calm the joint down. After 1 month you will have a new outlook on this, and we can email more. There are 3 phases of Rehabilitation: Immobilization, Re-strengthening, and Return to Activity and you need to be in the first phase for now. As the joint calms down, you then begin  to wean off the cast which can take 2 to 6 weeks. You need to be in shoes and inserts that provide protected weight bearing. Do not mobilize the joint for the next several months at least. The information gained from an MRI would be wonderful to have. 
     I try to tell my patients that there are 3 basic types of surgery for this condition: clean out (cheilectomy or arthroplasty), toe implants, and toe fusion. I love to have patients have a cheilectomy if the spurring is superficial (which yours sounded like), but even before they have the cheilectomy they must be ready for the implant if it does not work. Unfortunately, you really should not run with an implant, so your doctor probably just did not want to go there in that discussion. So, no one would argue too much if you had the implant. 
     Bone surgery takes time to heal, and we must honor that. Following cheilectomies,  some runners can get back quickly (3 months or so), but others take 6-12 months. It is a Bell Shaped curve. Most times this is hard to predict. 
     For now, cross train as you mentioned, ice several times a day, move the joint gently, often, but never with pain (since you can not know if you are hurting it), use the boot, get a carbon graphite plate, get orthotics that off weight, learn how to do dancer's pads and spica taping, experiment with hiking boots and shoes with rockers (like New Balance 980 or 928), and come to peace now that running may be back in 2015 or 2016. 
     I definitely would love to see an MRI now and in 6 months. In that 6 month comparison, you can get a great idea how the joint is healing, or not. Good objective decisions can be made then, not now. Avoid any more cortisone shots since it can mask pain and weaken the joint, unless you have definitely made the decision to do surgery in the near future. Honor your pain now, it really is your friend, it is telling you something. I hope this helps some. Rich

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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.