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Wednesday, June 27, 2012

Hallux Limitus: Email Advice

Hi Dr. Blake,

      I stumbled upon your blog when researching about Hallux Limitus. I am fairly young in my early 20's and am attending university.

      I have had some pain on my foot for some years now and have decided to get it checked out. I went in today to a podiatry doctor to look at my foot. I had thought I had bunions, but he said I had Hallux Limitus instead.

      He didn't really explain much to me and really rushed through my appointment. I was hoping you could give me some insights. I have done some reading online about this condition, and I do have questions about treating and surgery.

      The doctor did examine my feet, but no x-rays were taken. He did say that I do have some limitation of movement of my big toe. I feel like I need to know how serious it is before deciding what to do.

      I know I have the option of having surgery to remove the pain or doing non-surgical methods. I am leaning towards surgery, but I also understand that surgery may not be successful. What are your recommendations? Do you know the success rates for surgery and would I really need it? 

Thank you! Anonymous

Dr Blake's Comments:

Dear Anonymous: 

     You are so far away from surgery because you need to begin treatment first. Hallux Limitus can be structural with wear and tear changes of arthritis beginning in the joint, functional due to jamming of the big toe joint into the ground with over pronation or pes cavus foot type (high arches), or a combination of both structural and functional. So, you need to find out what type do you have.

     Functional Hallux Limitus does not need surgery, only orthotics or dancer's pads (also called reverse Morton's extensions) to take the abnormal pressure off of the joint. 

     Structural Hallux Limitus has 4 stages of advancing arthritis. As the arthritis gets worse, the pain can get better or worse. Seems odd, but often as the joint gets more arthritis the bone changes cause great limitation of the joint, and the joint stops hurting. Stage 1 and 2 are truly just joint limitations, and can normally be conservatively managed. I have seen just as many Stage 3s as Stage 4s (normally called Hallux Rigidus) have surgery as not need surgery. 

     Combination Hallux Limitus has both the structural component and the functional component. You have to first treat the functional component with orthotic devices to get the weight in the middle of your foot, freeing up the joint. The health care provider needs to be skilled at designing orthotic devices for such a weight shift. Then the structural component can be treated with Morton's extensions, spica taping, carbon fiber inserts, etc.

     So, before any thought of surgery, go through this checklist. You sound too young to end up with trouble with surgery. Surgery never fixes this back to normal. So postpone the first surgery as long as you can have success with conservative treatment. The goal of conservative treatment would be to allow 0-2 pain levels, while you are fully functional (doing every thing you want to do). 

     My checklist for Hallux Limitus for you would be: (all of this is on various of my blog's posts)

  1. Have orthotic devices designed to off weight the big toe joint.
  2. Have standing foot X-rays to check on the overall health of the joint and foot in general.
  3. Get an MRI before any discussion of surgery to check cartilage status.
  4. Learn to spica tape with kinesiotape.
  5. Discuss the opinions of 3 different surgeons when one surgeon tells you that your only option is surgery from this point on. 
  6. Begin a 1 year program of daily foot strengthening exercises.
  7. Learn the self mobilization procedure for Hallux Limitus.
  8. Ice pack your big toe joint area for 15 minutes three times a daily for at least one month to reduce inflammation.
  9. Learn what shoes and activities bother it, and what activities do not bother it.
  10. Never lean towards surgery, but rather but gently pushed there when needed by a caring doctor. 
      I sure hope this gives you some focus. Dr Rich Blake

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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.