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Wednesday, August 22, 2012

Day 1: Hallux Limitus/Rigidus

     Day 1: Hallux Limitus/Rigidus (A Discussion of Cindy's Predictament)

     Hallux Limitus is a stiffening of the big toe joint. We normally need 60 degrees of upward motion in that joint to move properly for day to day activity. Various sporting activities require more motion than 60. By definition, Hallux Limitus is less than 60 degrees, and Hallux Rigidus less than 30 degrees. When should you treat this problem? Always if it gives you pain. Will Hallux Limitus always become a surgical problem? Definitely No! Years I have treated patients with this problem and only a few require surgery any given year, emphasis on a few unluckly ones. Some patients put up with more pain, some patients don't need to wear heels, yet many patients with severe Hallux Limitus/Rigidus do no have pain that is unmanageable. I believe it is best to treat all of these as a sore joint, get the soreness calmed down, and then gradually develop a program around keeping the joint in the 0 to 2 pain range.

     This brings us to an email via my blog of a patient complaining of joint stiffness who then underwent the basic of surgeries for this problem called a joint cleanout or arthroplasty or cheilectomy. These joint cleanouts, much like knee arthroscopies, can last forever in alleviating pain, or not work at all. Joint cleanouts need a year to two to heal since the joint surfaces are scraped and cartilage involved. Any time you have a surgery that involves cartilage and the potential for slow healing, be ready for a slow going. MRIs are the best way at track the healing process of cartilage, but it is best to wait 3-6 months between MRIs. Golden Rule of Foot: The disability of the patient must match the disability of the first 6 months post surgery to make it a reasonable option.

Email from Cindy

     Hi dr blake, been reading your blog for quite some time, especially the HR posts. Used it to make what I thought was a good decision to have surgery March 7th of this year (she is 5 months post op at the time of the email). I had been told i had HR 2 years ago, after living with what i thought was bunions for many years. went to the podiatrist because of pain under my 3 and 4th toes, and much stiffness in the big toe. I love to hike and that was becoming increasingly difficult. even biking was painful because my toes would go numb.  I work retail, and have been wearing dansko shoes for several years, had a carbon plate made to put in some other shoes, also wore "rocking" sneakers - all of which helped a little.

      Anyway, decided i wanted to try and make life easier (ha!) so went for surgery. I had a chilectomy and first mtp joint (big toe joint) shortening.  All seemed to heal very slowly - i was told not to go for physical therapy by the podiatrist, but after several months I could not walk properly and thought pt might help.  I have a great pt who is very specialised in feet (wish i had found her before the surgery - she would have told me not to bother). she fixed the adhesion and helped me learn to walk again with the aid of hiking poles. I am back in my dansko shoes with a limp but am now having pain in my big toe joint where i never had it before.

     I am despairing now of being able to walk properly without pain.  All the podiatrist could suggest was surgery again to fuse the joint completely - would that be a solution or should i leave well alone for another 12 months or so? I still have quite a bit of swelling -another thing that my pt works on with a laser and massage. I do use ice and elevation after a day at work, but am pretty depressed about the outcome. I know that the rest of my body is affected from years of walking incorrectly, my ankles are pretty rigid, my knees are out of alignment and my hips and back suffer because of my odd walking habit. I am only 54 years old, played tennis and walked several miles a day until last year.

     My other foot is going in the same general direction, so am trying to get a sense of what i can do to help avoid this situation all over again!  would very much appreciate any thoughts on the situation.
       thank you so much, Cindy (name changed)

Dr Blake's Responses

Cindy, so sorry you are on this plateau between surgery and health. After a cheilectomy, it can take awhile for the bone swelling and pain to go down, so it is way to early to talk fusion. Cheilectomy is normally done when there is joint pain to begin with so those patients are more prepared mentally for this soreness. For right now you need to daily strengthen your foot, ice the top of the joint 3 times a day, learn to spica tape and see when you need to do that, get orthotics with dancer's pads to off weight the area, follow the smart advice of your PT, make sure you find the most comfortable shoes, and select activities that do not irritate. Remember one month at a time. Because I am short on time right now, please respond to this with further questions, comments. Rich

Cindy, some other thoughts, also remember that we must create a pain free environment. At times, I will place patients for part of the day in a removable cast like an Anklizer, until the taping, orthos, icing, Meds, PT, can calm the joint down enough! Tell me what helps you now alleviate pain. Rich

Cindy's Response

I dont take any pain relievers, ice helps when the swelling is bad. Often it feels as if there is a pin sticking under my big toe! this sensation is actually rather new.
 I try to be very concious of how i am walking, I do glute clenches which make me walk more evenly and "spread" my toes and try to keep my foot even as i put it down (sorry if that isnt too clear - my pt calls it "squishing the bug under my joint!).  I also often have a kinesio tape "splint" and various tapings which are somewhat helpful.  Discomfort is only present when i am walking, and occasionally when i bike (i have to be careful where i place my foot on the pedal).
My pt at first thought that the heads of the pins from the joint shortening were perhaps in the joint space on looking at my followup xrays, she sent me back to the podiatrist after we pondered that. He took more xrays and i looked at them with him, it didnt look like that but its pretty darn close! He told me that as my rom was bad before, what i have now was as good as it would get.  On relaying that to the pt, we did change tactics a little and stopped working on rom as much, just concentrating on my walking more "normally".
I am so very appreciative of your taking the time to read my email!

Dr Blake's Response

Walking is the easiest to alleviate pain. Is the pain from bending the joint or putting pressure on it or both? Definitely review on self mob for HR and begin to do daily. Ice three times daily whether or not you think you need to. If I could show you the bone swelling, you would understand. Rich

Cindy's Response

Pain is from putting pressure on it, on the upward motion doing rom there is discomfort but it's doable. My walking is such a mess because I can't toe off.
I will do ice and keep on walking,  I'm grateful for the encouragement.

Dr Blake's Response

Cindy,  definitely buy 1/8 th inch adhesive felt from and put as much dancer's pads in all your shoes and sandals. Various shoes will take various sizes and shapes. Golden Rule of Foot: With a Dancer's Pad, you should like you are taking pressure off the joint, not falling into the hole. They are easy to make. 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.