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Saturday, February 24, 2018

Hallux Limitus: Email Advice

Hi Dr. Blake,

I am a 34-year-old runner with Hallux Limitus and am hoping that you could help me. I have seen two podiatrists in my area (Lynchburg, VA) and they both have told me to just stop running. I run 20-25 miles per week (I did do a couple of 50k trail races last year but found that the steep up and down trails in the mountains irritated my toe). I am okay with not running these long races if it means that it will make my condition worse but I would love to be able to continue to run for many years.
Dr. Blake's comment: Hallux Limitus is either functional (which can be totally reversed with some arch support and dancer's padding to off weight), structural (meaning some degenerative process which will get worse and you still try to keep your pain between 0-2 and experiment with off-weighting and arch support), and structural and functional combined. If your big toe joints have some structural damage (typically diagnosed by x-ray or MRI), I would still run as long as you can in that 0-2 pain level. If long races increase pain, then you must avoid, but if 5-10 miles is fine, it is actually better for joints to have a pain-free high-level loading for cartilage nourishment.  

I do not want to ignore this and make it worse but rather run responsibly.
I have been running in Hoka Bondi's but I'm finding with the orthotics inserts a PT suggested I use (she has said I can continue to run), that the toe box is too small. I did try on Brooks Glycerin and Altra Paradigms and both shoes felt great but I'm not sure if they're great for this condition.
Dr. Blake's comment: There are some many factors that jam up the big toe joint, so it is experiment time for you. Definitely, find the wider Hoka One One shoes, they are out there. Hoka should be a great shoe for some of your running. Also, get a medium gel toe separator to see how holding the big toe in the center of its joint makes you feel while running. I love Brooks Addiction or Beast for the varus cant off the big toe, but of course, we do not want you to roll your ankle. Definitely, you want to see if those shoes, along with a 1/8th-inch dancer's pad to keep the weight in the center of your foot at push off. The zero drop shoes are good for metatarsal pain, but not good usually for hallux limitus. They put you back on your heels more, for pain reduction, but in most make it harder to push off. Some of my patients push off hard, and others hardly at all. 

Do you have any suggestions that will keep me running without irritating my toe or cause this condition to progress? Above If I take care of it and am cautious, does this condition always get worse? I would rather be proactive now than later.
Dr. Blake's comment: Have some weight bearing xrays taken of your feet, take photos of each frame, and send. Again, if it is primarily structural, you will have more work to do keeping in the 0-2 pain range. You would want to re-x-ray in 2 years and see what is happening. Arthritis is made worse faster by not using it, then if you can use in a pain-free environment. Look up the nutritional theory of cartilage development. Yes, if you have arthritis, and you push through pain, you will speed up the need to have joint replacement surgery. 

Also, do you know of anyone in the Central Virginia area that is up to date on this condition? 
Dr. Blake's comment: Call Richie and Company, an orthotic lab in Charlottesville, and ask who are the good biomechanics people in your area. They would know. Use my name. The owner is Brett Richey. 

Thanks so much. This whole thing has been frustrating and disheartening, to say the least. Also, I attached a picture of my most recent xray.
Dr. Blake's comment: The x-rays were poor quality and not sure if weight bearing. Have AP, Oblique, Lateral, and Plantar Axial xrays taken of both feet at some time and send me 8 individual photos. Please make sure they are weight bearing. Good Luck, Rich
Thanks again,

Monday, February 5, 2018

Considering Tackle Football for Your Youth: Please Read

This is a foot and ankle blog, but CTE, or Chronic Traumatic Encephalopathy, is bad and preventable. It is important as parents to at least discuss the subject when placing your child in a sport where CTE is a possibility. Is it Time to Ban Youth Football? When the Last Super Bowl be within the next 20 years? As a society, immune to change, unlikely. But, as an individual with a child you love, worth a few minutes of your time to ponder. Hate mail begin!!


https://www.huffingtonpost.com/entry/opinion-nowinski-ban-tackle_us_5a735bf7e4b0905433b23463

Sunday, February 4, 2018

When Is 0-2 Pain to be Ignored?

This patient is recovering from a serious injury, and at some point had to ignore my advice to create that 0-2 Pain Level for healing, and Push Through The Pain. When do we Honor, and when do we push through pain? Email discussion


Dr. Blake

Reading that advice to maintain 0-2 pain level concerns me a bit.  If I hadn’t pushed through the 7-9 pain I’m not sure I ever would have come back from my problems.  I think the first period I had to try to offload it to heal but once that time had passed I kept trying to keep the pain low and that I think attributed to the rest of my body breaking down.  The one thing that changed for me was the area of the pain changed over time. At one point or another, I had serious pain in about every part of my foot as I got my strength back.


Dr. Blake's comment: 

Hey, Yes, you are right. The 0-2 applies to typical orthopedic musculoskeletal pain, not the nerve pain you had. With nerve pain, there is a time to Honor the Pain and a time to push through the pain. You had to learn when to do both. It is very hard to tell someone to push through pain because you are not sure if they are hurting themselves. Physios with nerve training, and docs also, can help people but it takes awhile to get a sense from each person. You have to then test the experiment, push the envelope of pain, and see how you respond. Thank you for this very honest discussion. I truly appreciate this. Rich

And the Patient Responses: 
Agreed

Sounds like the guy needs to find a different doctor.  It really sounded like he's about to go down the path I did.  I went to 3 different Podiatrist and none of them knew what to do.  They all wanted to try to solve it with cortisone and I really think that is where my tears came from.  They didn't have those in the first MRI.   They would talk about surgery but I knew to go away at that point.   All Orthopedic surgeons I visited including Mayo, UAB, Andrews Sports Medicine and Birmingham Orthopedics said surgery was not a good idea for the situation I had.  The problem was they just didn't have a solution either!  


The more I think about it the more I think that shoes played a large role in my issues.  A Pedorthist told me that the New Balance shoes of all widths are now on the same footbed.  I believe that because I just can't wear them at all anymore.  If I put on shoes that put any pressure on the area I can immediately tell now that I need to stop wearing them.  Before I just thought it was "support".  Now I think it caused pressure on the area and caused at least part of the problem.  When the PT told me to get ASICS and I went with a larger size I could feel immediately there was not any pressure on the area.    I'm now getting into other shoes, boots etc and it takes quite a bit of time to find them wide enough but I know it when I find them.