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Friday, August 31, 2012

Hallux Rigidus: Email Advice

Hello Dr. Blake;

Found your blog and although I am a medical professional at a major hospital system and work with orthopedic surgeons I am trying to get as much up to date advice about my problems with Hallux Rigidus before I make a decision to go forward with surgery.

Although I am 60 years old I am a very active individual.  I was a Quarterback at a major university and suffered alot of turf toe.. I have realtively low archs and long toes.  I have continued with basketball, racketball, running etc. over all of these years.  I was diagnosed with Hallux rigidus over 15-20 years ago.  It never bothered me or affected my activities until a few years ago.  It is bilateral but quite prominent on the left foot. 
I have seen two othropedic surgeons and a DPM (podiatrist) about 2 years ago where they took x-rays and sent me to a sports medicine PT to have carbon fiber insoles prepared in which I have been using the last 2 years with fairly good results.
The xrays rays showed Grade3-4 involvement and as expected the amount of osteocytes on top of the joint esp the left foot is severe and in essence my joint is fused naturally. ( less than 10 degrees of flex)
Lately the bump ( osteocytes) have been causing me discomfort and I have noticed my ankle starting to be sore ( possibly from compensation)
I truly believe i will need to do something soon but I am so unsure and not wanting arthodesis due to recovery time and the unknown on how I will be able to be as active with a fused toe. 
I have read some reports that they have been actually trying arthroscopy for decompression to lessen down time.
My question on who to go to and does it make any sense in considering decompression with grade 3-4?  I know implants have not worked out well.

My othro friends just want to do the fusion - not crazy on that idea

any other ideas or insights would be helpful.

Bob (name changed)

Dr Blake's response:

Hey Bob, If you beat Cal (where I went) then I am not sure if I should be giving you advice, but I have not time to check the records. 

I share your concerns with fusion. 10 degrees is still 10 degrees of motion, and 0 is total immobility of that joint. 

I have no problem when the spurs begin to create problems to have those removed. This is called a Cheilectomy or arthroplasty (joint remodeling). At times, surgeons just do too much remodeling and cause the arthritic joint to move too much. So, the surgeon needs to have done some of these to know how much bone is safe to remove. Cheilectomies have a bad name since, for surgeons, it is not "to cut is to cure". Cheilectomies work wonders on many patients, but can have a long rehab period of up to two years. This is normally due to excessive bone swelling post surgery and inadequate bone removal or excessive bone removal. They can take a lot of post operative thought in the process. After surgery, the orthotics have to be changed, and the foot may have more pain!!

So, If I was in your shoes, I would find a surgeon comfortable doing Cheilectomies, some knowledge on who they work for, and no rush to do a fusion, since your joint is slowly and naturally fusing itself. The body can adapt quite well to a gradual process, but not so easily to a sudden change. This change is felt throughout the body and probably all of civilization. And, after I found that surgeon, I would have the bone removed that is causing the problem, and attempt my 3 to 24 month rehab, whatever it takes. I have never seen an active person do active weight bearing sports after surgeon, although you could be the next Lance Armstrong!

I work with surgeons day in and day out. They are like you and me. And they do what they feel comfortable with. You do not want a surgeon who deep inside wants to do a fusion do a cheilectomy on you. For many reasons, unless they are quite evolved, this could be disaster. I sure hope this helps you. 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.