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Friday, November 9, 2012

Hallux Rigidus And Abnormal Skin Discoloration: Email Advice

Hello Dr. Blake,

     I am a 56 year old female.  I have been dealing with hallux rigidus for three years.
Dr Blake's comment: Hallux Rigidus is defined as stiffness in the Big Toe Joint of less than 30 degrees of dorsiflexion (the bend of the joint as we try and push off). Normally the big toe joint (called the first metatarsal phalangeal joint) is between 75-90 degrees of bend. We normally need 75 degrees to comfortably function in sports, and 60 degrees for normal walking. This is a common measurement taken. 

     Tonight my pain level is around 7.
Dr Blake's comment: My favorite post on this blog is called Good Pain vs Bad Pain. Good Pain is considered pain levels of 0-2 on a pain scale of 0-10. 10 means you are in very serious pain and 1 means you are annoyed but still smiling since the San Francisco Giants just beat the Detroit Tigers in the 2012 World Series. 7 is getting very bad and we need to fix ASAP. 

     My left big toe joint is totally frozen.  It swells.  It bruises.  I walk funny.  Since Sunday my knee on that side is sorta clicking/popping when I walk.  My ankle swells.

    My foot looks awful.  It’s like it is continuously bruised around the joint, along the base of the toes and on the top of the foot though I think some might be due to meds that I take and sun exposure and the rest to reinjuring it over and over.  It’s ugly.

Dr Blake's comment: I definitely agree that the discoloration is something different than the normal Hallux Rigidus. It seems to especially involve the first 3 toes and could be some form of arthritic or vascular problem. Is the temperature normal? If it is colder, I would say see a vascular specialist, if warmer, an arthritis specialist. Is the pain all from the big toe joint, or are other joints involved? All Anti-Inflammatory Medication can cause abnormal bleeding. Simple blood tests can tell us if you have any abnormal bleeding problems. 

     I have never worn high heels in my life because I am tall.  For the past five years I have been limited to flats.  Three years ago I fell off of chair and came down on that toe.  I already had damage there but this time it was the worse.  When I went into the E.R. they thought it was a broken bone but found it was arthritis and bone fragments.  They referred me to a podiatrist.  I let it heal and did not go into the podiatrist until I damaged it again last winter.  This time I had pain throughout the foot and was put on steroids for soft tissue damage.
Dr Blake's comments: You are not going to get any absolution of your sins from me. When you keep ignoring the pain, the pain can become it's own problem. The skin discoloration could be a sign that your pain has been out of control too long. Prolonged pain can cause vasospasm (loss of blood flow) since the nerves feed the blood vessels. The loss of blood flow for too long can cause rebound increase blood flow which can cause skin discorations or ugliness!!! The vascular specialist would probably be the correct person in that scenario to see. 

During this first visit to the podiatrist he did x-ray my foot and said my joint had arthritis.  He gave me naproxen and sent me to have an insert made.  At that time the top part of foot over the big toe joint and then along the other toes was bruising.   Old looking yellowish yet darker in some spots.
Dr Blake's comments: Yellow, of course, is deep blood and the darker stains are the most superficial blood. Both of these colors are from the constant beating up on this or these joints. But, could indicate a bleeding problem. Please have some blood work including the standard CBC with Differential. 

 This bruising gets better and then worse when I hurt the joint accidently or wear shoes that are too soft.  Anyway, I never got the insert made.  This past year the pain has been getting worse.  This past weekend I wore new boots with the same heel as the other boots I wear.  I wore them around for around five hours and it got increasing more painful to walk.    When I got home my foot was throbbing.  I took off the boot and it felt like my joint was coming apart.  It hurt and the area around the joint swelled as well as my ankle.  I did walk though and by Monday the next morning it was somewhat better.  I was limping and it was really sore and I am yet today.
Dr Blake's comment: I know when you have something for a long time, you just want to ignore it and live life. However, this problem is crying out to be treated seriously, and you must start with creating a pain free environment for it, and keeping it pain free for 3 to 6 months. This probably will mean a removable cast, like the Anklizer, to reduce the bend in the joint. Perhaps just a shoe like the MBT will produce less bend to minimize the discomfort. In this task however, you should be armed with good protective orthotics and the skill of spica taping. 

Fortunately I had an appointment with the podiatrist that same day Monday.  Again I went in and he did x rays and said it was bone on bone.
Dr Blake's comment: Bone on Bone means that the cartilage (pillow) covering the bone is gone and the bone nerve endings are exposed. Pressure from the opposite side of the joint produces pain since the pillow is gone. Cartilage has no nerve endings, so in a normal joint you do not feel the joint moving. In an arthritic joint, with exposed bone on one side of the joint hitting exposed bone on the other side of the joint, the nerve endings produce a lot of pain with this pressure. 

 While examining my foot he asked me if I was diabetic.  I told him I was not.  He said my foot looked the way a diabetic foot looks.  He was referring to the discoloration/bruising.  I told him about the meds I take (nipedipine and hydrochlorthiazide) and what I thought some of the discolorations were along with injury.  He really did not say any more about that.  He then gave me three options.  Do nothing, joint replacement or fusion.  I asked him what he would do and he said if it was him he would probably do the fusion.  He set me up to have the surgery on November 15th.
Dr Blake's comment: If you are pre-diabetic, signifying possibly poor healing, you need to get that checked out before any type of elective surgery. Check if your drugs for high blood pressure can cause easy bleeding. Definitely, you need you internist to work things up and make sure you can have surgery in the first place, or do you need to get your circulation, blood sugars, platelets, etc, evaluated?

I asked him if there was anything I could in the meantime meaning wrapping…something.  He said just carry on til then. 

That’s a long way away.  I have stairs in my house and my knee is making a sound/feeling every time I go from my room down to the living area.  I am limping up and down and not putting any weight on that area.

I don’t want surgery but I know something needs to be done because of the pain and the swelling.  Right now I want to call my podiatrist and ask him for a boot just so I don't have to hurt that area anymore but I am leery as he did not recommend this on Monday.
Dr Blake's comment: Doctors are human, at least some of them. You need to feel comfortable with any doctor who is making major decisions about the rest of your life. If you do not feel comfortable calling him, switch to another doctor. But, I would encourage you to stay with him and call. Doctors can not remember everything in the short time of the visit. Golden Rule of Foot: If a doctor does not discuss something you think is important, it is important, and they were just thinking of too many things at the time. So ask!!!

Do you have any ideas?  I want to walk again.  I want to exercise.  I feel like a cripple.  I am active though not athletic.   I hate the way the skin keeps being so discolored as if I broken bones.  Please give some me some advice.  I am wits end. 

The one good thing.  When I lay down I have no pain.  It's sore but it does not hurt.  But I can't lay down for the months or years...can I?  Nope got to work. 

Thanks for your time
Linda (name changed for privacy)

Dr Blake's initial response:

Linda, I will have more time this weekend to explore your email. Definitely you should be in a removable boot for the next 3 months while you analyze the pros and cons of various surgeries. I will help. I need photos of your foot, copies of your MRI and xrays. I prefer you cancel surgery while you really think this out. Rich You also need to have a good vascular workup to make sure you will heal from any surgery. 

 Hello again,

Thanks so much for replying.  

You do not know how much I do not want to let anyone see my feet.  I looked at pictures on your website and mostly their feet look healthy.  Mine look disgusting.  If only they could just look and feel halfway good i would be happy.   

I took two pictures with my cell phone.  Not good light.  I can get better pictures too.  

I also have a nail fungus which I asked the Podiatrist to treat, he wants to prescribe the antifungus meds which I refused at this time.  i wanted to read more about them.  And I wanted the joint pain taken care of first.

I can request xrays but never had an MRI on my foot.  

The tips of my toes are pink.  There is no bruising on any of them.  I wore open top shoes up to last month and both tops of my feet are discolored.  The right foot top is dark like a permanent tan but not bruised like the left.  The bruising was not as bad before I wore the boots on Sunday...anything constraining makes the swelling and bruising worse.  If I know it is nothing I can live with discoloration but what is causing it?  The damage to tissue? And i want to believe part of it is meds.  I also take synthyroid.  

I realize it is late and I don't expect any answers... I just have to ask the questions.

Thanks again

Dr Blake's response:

Hey Linda, So here are the steps you need to do if possible over the next few months. Get a vascular workup to make sure you do not have any bleeding problems that would interfere with surgery. Get an MRI to document the status of cartilage destruction on the joint. Get another opinion after these on the viability of conservative care vs joint cleanout vs joint replacement vs joint fusion. Definitely get into a removable boot with EvenUp, get orthotics that seem to place your weight into the center of your foot, learn to spica tape, and ice twice per day. I sure hope this has been helpful. 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.