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Thursday, April 6, 2017

Big Toe Joint Injury: Possibly Turf Toe

Hi Dr. Blake,

I came across your blog on the Internet and it is one of the most valuable resources I have ever come across in terms of foot health. I understand you are super busy but I would be extremely grateful for any advice you could give me.
Dr Blake's comment: Thank you so kindly. I am trying, I love teaching and I love podiatry. So thank you!!

Approximately six months ago, I suffered an avulsion fracture on the metatarsal joint of my big toe. I wore a boot for six weeks, and pretty much was pain-free once I took it off. I did have a bone spur/swelling to the side the joint, and my range of motion was much more limited with my big toe, but I was nearly pain-free and able to walk.
Dr Blake's comment: If you injure the joint enough to get an avulsion fracture, then you had to technically develop a version of Turf Toe. or plantar plate tear. You will have to tell us later in the comment to this post how the original injury occurred. The ligament attaches into the bones, and when the ligament is pulled too hard, either the ligament tears or the bone avulses. Either way you are left with some instability in the joint. 

Unfortunately, around New Year's day I made a very dumb decision. I performed a deep lunge and pushed off this same big toe when I was in deep flexion.

I immediately felt the pain come back, but I was still able to walk normally without any sort of limp. Unfortunately, I stand and walk on my feet all day for my job, and As the month went on The pain either intensified or stayed the same, but did not get better. 
Dr Blake's comment: So you need MRI or at least comparsion AP feet x-rays. The x-rays are taken standing and you compare the sesamoid position right to left foot. Then, with the toe bent upwards (still standing) 30 degrees another set of xrays see if the sesamoids are still equal in there position from the joint. You are trying to get an idea if the joint is asymmetrical to the other joint in how it functions. 

By February, I decided to take off time from work so I could focus on resting and getting off of my feet. I also saw a podiatrist who thought I might've had a sesamoid injury. I got an MRI and bone scan done, but there was no signs of a fracture at the sesamoid and my ligaments were intact. This was on or around February 1, 2017. I attached the MRI report, were you able to read it? I did say I had a mild nonspecific edema and other things as well.
Dr Blake's comment: The nonspecific edema in the third met is probably a stress reaction from limping. As long as it does not hurt there, no big deal. The ligament structure of the first metatarsal phalangeal joint, including the intra-sesamoid ligament, was ignored in the report. Ask them to look at this further. I am also happy to take a look. Send the disc to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. 

Now being that it is April 1, the last two months I have spent resting and healing the best I can. I am walking in normal shoes with inserts + dancer pads in them, but I still get occasional twinges of pain every so often.
Dr Blake's comment: I would definitely start taping the joint with Spica taping and see if it influences the pain. Also get flat Otto Bock carbon graphite plate to wear under the shoe insert and see if that helps. 

https://youtu.be/l_4HESXCG40

I just got back from the podiatrist today, and he noted that he thought it was a complicated injury. Between my avulsion fracture or of the metatarsal joint, re-injuring it when I performed a deep lunge, and standing on my feet nine hours a day at my job, I developed a chronic condition. He noted that there was probably a lot of information in there. And also that when I did my deep lunge, I probably aggravated it and resulted this with some turf toe. So: My ligaments and tendons were probably partially torn, completely torn, or definitely at least injured. He said this could take 6 to 12 months to heal, which I am accepting. At this point I just want the best situation possible and I will do whatever I need to.
Dr Blake's comment: Sound smart (because he agrees with me!!)

My main question is in regards to barefoot walking. The podiatrist says I should continue to hold off on barefoot walking as long as possible. I agree with him to an extent, however sometimes it just feels really good to barefoot walk. Honestly being barefoot is one of my favorite things in the world, probably one of the things I miss most since my injury.
Dr Blake's comment: Barefoot is fine, as long as you don't jerk the toe and have to start over. You have to create the 0-2 pain level consistency of a healing environment. Try spica taping during this time. 

I've noticed that when I do barefoot walk, my gait has definitely changed a little, I no longer push off of the big toe on my left foot anymore(because if I did, there would be pain and so my body automatically adjusted how I walk).
Dr Blake's comment: In my mind, that answers it. You have to not limp, or we will be talking of a more serious injury in the hip or knee or low back in several months. Test out barefoot walking monthly, and as the symptoms calm down, you may be able to walk barefoot more and more. 

He did say I could start doing strengthening exercises and also that I could start swimming again, which I am really excited to get back to some activity. However, I still really miss being able to run, jump and dance. And I am fearful that I will never be able to hike an inclined hill again. Hopefully six months or a year or two years or even five years from now I will have improved enough though, to where I can walk on at least gentle mountains again, anyway.
Dr Blake's comment: Really, if you developed Turf Toe, and you go on for awhile without improvement, then they need to find the ligament to fix and put some stitches in it. This is normally not a big surgery, and it has good results, but it can not be just an exploratory operation. The surgery starts a 1 year process towards complete healing and complete function. We expect complete function with some joint stiffness, but not pain. 

Anyway, what is your opinion on barefoot walking? How do I draw the line between "using my feet muscles/toes/connective tissues enough that they retain their function and gain strength and mobility", versus "using them too much that I slow down my healing or possibly re-injure them, because further inflammation/damage?"
Dr Blake's comment: No limping, and no pain over 2. 

He seemed really adamant that I should avoid barefoot walking as much as possible. Do you tend to agree with this?
Dr Blake's comment: See above. Plenty of my patients walk barefoot at least around the house with spica taping and 1/8th inch adhesive padding from www.mooremedical.com stuck to their foot and are fine with the above limitations. 

I noticed that you talk about having a 0 to 2 pain level, but I am able to walk pretty much pain-free barefoot as long as I use short strides and I'm careful not to push off from my injured big toe.
Dr Blake's comment: That sounds fine. The injury is one that you have to avoid bending the joint for a good period of time, but this has not even been documented, so I hope it is true. It is not the weight bearing, it is the bending. 

Any thoughts? Maybe I could still do a little bit of barefoot walking every day, and gradually build up overtime? Or do you tend to agree with him, that I should avoid it at all costs?

Just wanted to grab another opinion if possible, because I know there is the debate between wearing shoes/protection(which protects you more, but in theory could actually atrophy your feet/toe muscles more?) vs walking barefoot(which engages your feet/toe muscles and could potentially strengthen them and help them regain function, but also leaves them more vulnerable to further injury)
Dr Blake's comment: I am definitely in the middle, some of both because sometimes you need the protection (running a race hard downhills on irregular rocky roads). When you can get away safely barefoot, go for it. 

Additionally – – he said that I could see a chiropractor if I wanted to. I was planning on seeing one maybe three or four times total, for them to do a joint mobilization on my big toe and see if that might help me regain some motion. Since I cannot extend it downwards very far.
Dr Blake's comment: I love chiros, but you do not have an actual diagnosis, and if it is Turf Toe, you are trying to let it get stiff and scarred right now. It is all about timing, and I am not sure it is the stiffness that is giving you pain. 

To clarify – – I am not doing extreme amounts of barefoot walking. Just when I am walking around the house and relaxing. I will obviously wear shoes anytime that I go outside or go on a long walk. However, if you also have a strong opinion that barefoot walking should be sharply avoided, then perhaps I should be putting on my shoes even when I walk 15 steps over to go to the bathroom. I am willing to do whatever it takes to give myself the best chance of regaining activity.

Thank you again for any help that you can provide me with. This has been a really tough injury to deal with, but I am really thankful for the help I have an able to receive, and it's giving me a lot of time to focus on myself.

Thanks!!!

PS - I attached a picture of my feet, you can see that on my left foot there is a much bigger band/bone spur near my metatarsal joint where the injury has occurred. I also attached a picture of the MRI report.



Sorry these are on their sides!!







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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.