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Sunday, April 21, 2013

Plantar Plate Tear Big Toe Joint/Turf Toe Injury

This is a continuation of a previous post.

Hi Dr. Blake--I wanted to give you an unfortunate update with my foot jog your memory, I mailed you an MRI weeks back, and you indicated that you saw a plantar plate tear at the right big toe. My ortho. agreed, and he told me that a few weeks in the air cast boot would be plenty to heal it completely--he acted as if this was a very minor injury, and that I should be healed in no time. I have a follow-up with him in 2 weeks, but I wanted to share my not-so-much progress with you....

It has been 8 weeks in the aircast boot with no progress. I am not working out or doing anything beyond walking in a parking lot, from my car to work, etc.  I do have to admit that when I am at home, I take off the boot to breathe a little and walk around (minimally) -- I make sure not to bend my toe or anything.... Anyway, I feel no progress. My foot is still swollen to the point that my shoes no longer fit the foot (I only put a shoe on to make sure that I was not imagining the swelling). The swelling appears to make my foot wide--I think what swells is the arch area, esp. underneath it. The swelling occurs both in and out of the boot, with walking and without walking. I also still have pain at the top of the big toe, and around the ball of my foot and arch. O, and when I elevate my foot, my big toe sometimes twitches uncontrollably.
Considering that 8 weeks was the top of the healing timeline--do you think that there is an additional problem here? I am saddened to not feel any progress and REALLY scared. Why the swelling at this stage, and why the same type of pain? If you remember, you ruled out the possibility of semamoid fracture when you looked at the MRI I mailed--my ortho agreed. The podiatrist, however, still is diagnosing me with sesamoiditis and a possible sesamoid fracture.

I am attaching a picture of my swollen foot--I am so embarrassed to be sharing this with you, but I feel that I have no choice but to do so. The right foot is the swollen one--it may be difficult to tell, but its much wider than the left, and much more red in color. I can't believe I mustered the courage to attach this awful pic, but...I am assuming you see worse. The pic doesn't do the swelling justice, but trust me, my foot does not fit in a shoe that I could fit into with absolutely no problem in December.

Does my non-progress concern you? Like I said, I am seeing my ortho in a couple of weeks, but also wanted to get your thoughts on all this.

Again, thank you so very much for your help, always.

Dr Blake's comment:

Adele (name changed), 

     Thanks for sharing. I am sorry you are struggling so. Most likely, the immobilization and velcro straps from the boot are not allowing the blood to return easily into your circulation. This will make you hold swelling and it is a common part of immobilization. It is important to begin to ice the foot for 10 minutes 2 times daily and do contrast baths (see blog) each evening. Every chance you get have the boot off and massage the calf where the velcro straps are. Whether you are in the boot or out of the boot, elevate your foot somewhat off the ground (even inches can help). Keep your knee slightly bent to avoid irritating the sciatic nerve. You have to work hard on creating a pain free environment. I am assuming that your foot does not hurt in the boot. Since you are at 2 months with all this swelling, physical therapy will be in order once the doc says you are ready. Maybe they can get you out of the boot now and into a flat post op shoe for the swelling. That would work really well. The twitching is your nervous system not liking something. Perhaps it is the boot and the torque on your spine. Are you using an EvenUp when you are wearing the boot? Perhaps the swelling in your foot is compressing the nerves from within. It is good you had the MRI so you can have a comparison if another is needed in the next 1-3 months. Try to massage your foot daily, without eliciting the pain response, to reduce the swelling and get some biofeedback to the tissues that the area is okay. I hope this helps you some. Rich

Thank you for your wonderful suggestions. I was feeling very worried and I moved up my doc appt to earlier this week. He was not impressed by my state and told me that I am ready to take off the boot and walk in normal shoes. He told me to walk through the pain and that to worry only if the pain is great enough to make me limp. I am also going to start PT - he said it would be painful also. I walked without the boot today like an idiot and I am complelty back at square 1. Same exact pain that got me to the podiatrist in the first place. If I'm just not going to heal - what is my worst case scenario here! Dr Blake ? Do they surgically repair grade 2 big toe plantar tears? Would it be a difficult surgery and recovery ? Have you heard of a grade 2 tear not healing on its own ? I'm sorry to bother you , I wish that your office wasn't across the USA for me !! Thank you again.

Dr Blake's comment:

Please go back to the boot full time, ice three times a day, then email me on Monday. Rich

Hi again Dr. Blake--thank you for the suggestion. I put the boot back on and the pain did improve a bit; the swelling continues with/without aggravation, the pain that I have remains in the ball of the foot and the base of the big toe (almost to the side of towards the second toe), and also at the big toe joint while pushing off...  I have also been icing and elevating. I will start PT this week sometime.

I do not understand why my foot ortho (who is well regarded in my area) would tell me to take off the boot and walk through the pain although I showed no outside signs of improvement. I am annoyed at myself for listening to his suggestion, which went against my gut feeling--I guess I just wanted to wear 2 shoes again!
Dr Blake's comment: I hate when time limits are put on recovery. The 4 week, 8 week, etc rules are just general rules, and must be individualized. I like the Phases of Rehabilitation better. You are presently in the Immobilization/Anti-Inflammatory Phase and dying to be the Restrengthening Phase. You have to ween off one phase, while carefully entering the next phase. I believe Physical Therapy is going to be crucial. To strengthen your foot enough so that you can begin the Return to Activity Phase, physical therapy is going to have to do the following:

  1. Painlessly wean you from your cast
  2. Painlessly restrengthen your foot
  3. Remove most of the swelling (at least the amount that hurts)
  4. See if you have any limitations on overall strength, flexibility, joint stability, functional activities
Then, they will have to guide you how to regain all of your pre-injury activities: starting with the least stressful on the joint, and progressing to more difficulty. 
     This delicate balance is why physical therapists and athletic trainers rule the rehabilitation of all the professional sports teams. The orthopod or podiatrist is called in for diagnostic and procedures only. 

I have a few questions, and hope to get your thoughts... Just to keep it organized on my end, I am lumping the questions below. Again, thank you for giving me support all the way from across the country. Your responses mean a lot, and I value your opinion.

1) is it possible to un-do any progress i have made to the ligament in the last 8 weeks by walking through pain and without a boot for 1.5 days? as the pain that was elicited while walking was the same exact pain that got me to the doctor in december, at the beginning of the injury?
Dr Blake's comment: Daily an injury gets more healed and less fragile. Feeling the exact pain is no indicator of complete set back. Feeling the exact pain just means you picked on the weakest link in the chain which is the injured area. It is hard to completely re-injure something, your body's self preservation system normally prevents that. Flare ups are more judged by the amount of time it takes to get back to where it was before the flareup. 

2) my non-progress at 10 weeks of immobilization seems weird to me, as the plantar plate tear has been described to me as small and located in a stable spot. i have been diagnosed with a slight bunion on this big toe-could that be interfering with improvement? i bought a toe separator yesterday and have put it on. neither aggravated or improved any symptoms.
Dr Blake's comment: You have so much swelling in the photo you sent that it is normal to feel no progress at this stage. What appears to be a concern is whether or not surgery will be indicated? It takes months and months for me to decide on surgery in these cases. And since only less than 5% of patients with this injury need surgery, you will really have to prove it to your doctors that you need it. Forget the length of time, listen to your body, get to a good physical therapist knowledgeable on this injury (or at least likes to deal with foot injuries).

3) most importantly: what is my worst case scenario here? lets say that another 3 months pass and i see no improvement. is surgery an option for grade 2 turf toe if it doesnt respond to conservative measures? how likely does conservative treatment fail for an injury like mine? and, how difficult and effective is surgery, as a last resort?
Dr Blake's comment: Of all the Plantar Plate aka Turf Toe injuries I have seen, I have never seen surgery to an isolated ligament tear when it involves the big toe joint. The big toe joint is so intrinsically stable that it tends to heal well. The same injury to the 2nd joint leads to surgery probably 50% of the time. I am sure however that surgery does happen, sometimes just to explore the joint when it keeps hurting for no explanation. A surgeon will have to give you some direction. My favorite recommendation in that area of a podiatrist is Dr Stephen Pribut if you want a local doc to give you another opinion. He is just wonderful. 

4) lastly, any recommendations for a podiatrist in the washington DC metro area? See answer above.

THANK YOU VERY MUCH DR BLAKE. you have been a blessing in this awful and painful journey.

One of those wonderful Hawaiian flowers

1 comment:

  1. I have kind of a similar problem here? 3 Months with only minimal improvement. Do You have any updates for your healing process? I am really desperate, and dont know what to do anymore


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.