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Sunday, June 22, 2014

Big Toe Joint Injury with Hallux Rigidus: Email Advice

Dear Dr Blake

I am emailing to say thanks so much for your blog - it is the clearest, most thorough and most practical site I've come across in all my web searching and I really appreciate it.

I can only imagine how busy you are already answering all the questions on your blog, but I'm also emailing to ask if you could possibly give me some advice.  I have had pain in the ball of my foot for the last 5 1/2 months. At first it was intermittent pain, which felt like a stone bruise under the ball of my foot, but gradually it became more persistent and more painful. Now it is painful all the time and feels like a hot needle in the joint.  Originally I was walking to and from work each day, but had to reduce the amount of walking I was doing, and then reduce it again, and then stop altogether. Despite this, the pain continued to get worse.

It has taken 5 months of various misdiagnoses and so incorrect treatment before I finally got an MRI and was diagnosed with grade 4 osteoarthritis of the lateral sesamoid-metatarsal, with cartilage loss, bone marrow oedema and some osteophyte formation.  (The exact wording of the MRI report is "There is a bone marrow oedema pattern elicited from the lateral sesamoid.  There is no sesamoid fracture or osteonecrosis.  There is lateral sesamoid metatarsal osteoarthritis, with high-grade partial thickness cartilage loss over both sides of the joint and focal exposed bone laterally.  Marginal osteophytes arise off the lateral sesamoid-metartarsal articulation. There is degeneration of the lateral sesamoidal phalangeal ligament which is hyperintense but is not torn.... There is a moderate reactive joint effusion at the MP joint.  Mild reactive bone marrow oedema patter is elicited from the central plantar aspect of the metatarsal head.")
Dr Blake's comment: Okay, you have Hallux Limitus Rigidus/Limitus with degenerative arthritis in the big toe joint. The pain you get is that the joint between the lateral sesamoid and first metatarsal head is inflamed, and everytime you put pressure on the lateral sesamoid it pushes against the sore inflamed first metatarsal head. 

I know you've already answered some questions on sesamoids, all of which I've read, and that has been really helpful.  However, I still am at a loss as to how I should proceed with my own sesamoid problem, and I have received a lot of clearly conflicting (at at times plain wrong) advice so far.
Dr Blake's comment: First of all, you have had this process for years slowly developing, so why does it start hurting now? You can take 2 approaches: remove the lateral sesamoid (not my first choice but probably helpful), or go 3 months in a removable boot with off loading padding and bone stimulator to see if that really calms the joint down. Following the 3 months of boot is a 3 month weaning process off the boot developing protective weight bearing orthotics, shoe selection issues, and foot re-strengthening.

Since my diagnosis I have been frantically googling to try to find out more, but most of what I read is about stress fracture (rather than chronic inflammation).  What I have read online about sesamoiditis is about the tibial sesamoid, with very little written about the lateral sesamoid.

I'm really surprised by the diagnosis because I'm only 45 and I don't fall into any of the usual risk groups - i.e. I've never had an injury to the foot, I never wear high heels, I've got no family history of arthritis, I've never been overweight, I've never had a job where I had to carry heavy loads, and I've never been an athlete and have never been a jogger or done any high impact sports.  I don't have lupus, and I've only got this in one joint, so I understand that means I don't have rheumatoid arthritis.
Dr Blake's comment: Unfortunately, simple mechanical issues like a long first metatarsal and big toe, and/or over pronation can slowly breakdown the joint (along with other issues). The process could have started 30 years ago, and been quite glacial in developing. Do you have a toe first toe? Do you over pronate? How is you bone density and Vit D levels? 

The orthopaedic surgeon I saw said that what I had was extremely difficult to treat, that surgery was not an option he would recommend (or do), and suggested an orthotic cut out.

He referred me on to get a steroid injection, which I'm getting in two days time. He seemed a little non-plussed when I asked him about follow up, and when pushed, suggested I see him again in three month's time.  I've decided I need to rest my foot more to give the cortisone injections the best chance of success so I've arranged for one and half weeks off work after my steroid injections this week, and I've arranged non-teaching duties for the next half a week after that.
Dr Blake's comment: Please avoid the cortisone, unless it is short acting. The long acting can make you feel great for 9 months while you are continuing to do damage. At least think it through as well as you can. I tend to recommend cortisone shots in these situations when surgery is the only other option. I personally think you have many options. 

The orthopaedic surgeon said that there is no exercise I can do that will make it better or worse - I find this hard to believe as although I understand that osteoarthritis is a long term degenerative condition, in my experience there is always some kind of exercise that can have a good or bad effect.  I'm contemplating seeing a sports medicine doctor for a second opinion in the hope that someone like that would be more interested in rehabilitation options.
Dr Blake's comment: Sure, you want to avoid exercises that emphasize bending the toe at push off, but elliptical and cycling, and swimming can normally be done safely (perhaps with a slight modification). 

So, what makes the pain worse are standing, walking and balance exercises.
Dr Blake's comment: You need to develop orthotics that off load enough to allow for standing and flat foot walking. You can balance in the middle of books arranged where their is a hole for the big toe joint to sit in to off weight. You really need to be placed in the Immobilization phase however for right now. If you use an Anklizer boot with float to off weight and then ice pack 20 minutes 3-4 times a day to bring the inflammation down. 

And what I've tried so far in terms of treatment:

Foot exercises (toe spread, metatarsal lift, theraband around toe) - but these made it worse, especially the theraband, so I stopped.
Dr Blake's comment: This is because you are in the Immobilization/Anti-Inflammatory Phase of Rehabilitation. These exercises will be great 4-5 months from now. 

Calf muscle release - didn't seem to make any difference so I stopped.

Anti-inflammatories (causing stomach problems but I'm persevering) and fish oil
Dr Blake's comments: I would save the pills, and go to direct icing, and perhaps once a day contrast bathing with one minute heat/one minute ice repeated for 20 minutes. It may be too early however for any heat. 

Cushioning - originally metatarsal pad (given to me by podiatrist), then a metatarsal pad that I cut a hole in for the sesamoid, but now after online research, I've fashioned a type of dancer's pad made of 1/4 inch foam.
Dr Blake's comment: Great, I love my dancer's pads!!!!

Arch support - through taping and through a store bought with arch support.  Have since been told (by orthopaedic surgeon) not to bother with arch support.
Dr Blake's comment: I love the red Sole insert which is in stores all over (like REI). You can adjust them endlessly since there is no plastic. Sometimes, a shoe repair store, which their handy dandy grinders can help if you need to remove an edge. The role of the arch support is two fold--shift weight into the arch and shift movement towards the center of your foot if you pronate as you roll through your foot into push off. 

Toe taping - I'm also now taping my big toe to restrict upward movement.
Dr Blake's comment: Yes, I love Spica taping!!!

Icing - Generally my foot hasn't looked obviously red or puffy but I've been icing it one to two times a day.  However, I went back to one of the many physios I've seen last week and he noted that the tendon area looked puffy.
Dr Blake's comment: Ice, ice and ice. At least with icing you can multi task. You can ice the bottom of your foot while brushing your teeth, checking emails, eating breakfast lunch and dinner. 5 minutes minimum and 20 minutes maximum. 

Cam boot - At no stage has any of the physios, podiatrist, doctor or orthopaedic surgeon suggested immoblisation of my foot (despite the problem previously being misdiagnosed as a stress fracture).  However, I've decided to give immobilizing it a try, and have rented a cam boot which I've been wearing (with my foam dancer's pad and toe taping) for the last 5 days.
Dr Blake's comment: Yes, minimum of 3 months!!!! 

Up until this point, I've been continuing to go to work, and to my weekly pilates class, but I have cut out all other exercise except that which I can do at home on a mat.
Dr Blake's comment: You need to create a pain free environment. Try to keep the pain level between 0-2, no matter what you are doing. 

I've asked my usual physio to help me put together an exercise programme for the future that replaces the daily walking I used to do with something else, but think for the short term I really need to stop using my foot. This is a problem for me as I have nerve pain down my back that I usually manage through various forms of exercise, the main one being walking (and making sure I don't spend too much time seated). I also have a job where I'm on my feet a lot (teaching).
Dr Blake's comment: Make sure you purchase an EvenUp for the side that does not have the boot. It will help protect your back. 

So my questions are:

I've read that usually you only immobilise a fracture or break, but is it ok for me to use the cam walker? Yes
And if so, for how long? 3-6 months really, but we can talk when you have been 1 month straight in the removable boot and 0-2 pain level has been maintained. 
 Up till my steroid injection? And after my steroid injection? Please delay thoughts of cortisone for now, unless it is only short acting, but I would ice for a month first and wear the boot and see how the inflammation goes down. 
What is usual follow up after steroid injections into a joint - the orthopaedic surgeon said to see him in three months, but shouldn't I have a follow up appointment sooner than that? Isn't it common to need more than one steroid injection?
Do you have any recommended rehab exercises I should do after the injection?
What's the best shoe for someone with my problem? Are rocker type shoes worth the money? Is a stiff soled shoe the best, or a more cushioned type shoe better? Typically you go from removable boot to stiff soled shoe like a Hike and Bike or New Balance 928. While you are in the boot, you are getting a bone stimulator (Exogen) and getting your orthotics perfected with the right arch support and right amount of dancer's padding. 
Why is the lateral sesamoid less commonly a problem than the other sesamoid? Supposedly it bears less weight than the tibial, especially when you pronate or if you have any amount of bunion. Both off weight the lateral or fibular sesamoid and load more the tibial sesamoid. 
 Does this make it harder to treat?  Does this have any implications for treatment? Yes, but not really. Subtle padding issues, surgeons more prone to just remove. I think you have more Hallux Rigidus symptoms right now, and less sesamoid technically. The sesamoid and lateral first metatarsal head cartilage issues means a bone stimulator is crucial. 
Why have I got this and will it continue to get worse? Sounds degenerative which is somewhat luck of the draw. For me it is my back, another the hips, another the ankle, etc. Yes, but learning to live with a problem like this is what sports medicine is all about. Do not feel alone, the world is with you!! And one of my Golden Rules of Foot: Teach the patient, not the imaging results. Another Golden Rule of Foot: Listen to your Body and let it help you create a healing environment. 

(I know you probably can't answer that, but it is really playing on my mind!).  I'm very worried about the long term prognosis for my foot because I'm quite shocked at how quickly it has deteriorated. The pain came on quickly, called a flareup (your first one, which is also the most disconcerting one!!), but the process is very slow in general. You will learn this next year how to minimize the time of flareups, what activities pick on it the most (I purposely gave up golf with my back due to the torque, but have been able to play full court basketball with no problem), develop a relationship with a good orthotic maker, begin a lifetime of foot strengthening exercises, learn to select shoes that you do not pronate into, etc etc. A bunch of learning!!

As I said before, I'm sure you are very busy, but if you can shed any light at all on any of the above, I would really, really appreciate it.

Kind regards

Cindy (name changed)

Dr Blake's comment: I hope my above comments start you towards healing, but you sound like you are already figuring it out. Rich

Here is the patient's response to this post:

Dear Doctor Blake

Thanks very much for taking the time to answer my email.  I'm going to do some reading up about Hallux Rigidus, as suggested.  And don't apologise for disagreeing with previous advice about the steroid injections - I know everyone has a different take and in the end I will have to make my own decision.  My GP has, like you, said that I’ve probably had arthritis for a long time, but only noticed it because it got inflamed and didn’t settle down. She seems to think if I can calm the inflammation down, it should improve, so she's supported the idea of the injections, but honestly, I not sure what I'm going to do.
Dr Blake's comment: You can also consider an 8 day Prednisone (oral cortisone) Burst or 5 PT visits using topical cortisone with Iontophoresis. 

  I think she's probably influenced (as I'm sure I am) by the fact that I need to keep active to manage the other ongoing muscular skeletal problems I have. I am tempted to do the injections and do the immobilisation and all the icing, contrast baths, supplements etc that I can, basically blitz it with everything I can.  Anyway, I've ordered an 'evenup' and am going to keep going with my gut (and your advice!!!) in the meantime and keep on immobilising my foot.  I'm interested in the EXOGON device you recommend - I read about this in a post on your blog from another person in Australia (that's where I live), and he mentioned renting one.  I'm going to investigate it further.   How long do people use these for - is it for long term maintenance of joint cartilage or just for acute stages? 
Dr Blake's comment: It is for the next 9 months to see if the cartilage under the first metatarsal head and the injured sesamoid can strengthen themselves.

In regard to your questions: 
. Do you have a long first toe? .Do you over pronate? How is you bone density and Vit D levels? No other problems with any other toes.  No real biomechanical problems (according to a couple of podiatrists in the past about other issues), bone density fine (got it checked after I was initially told my foot problems was a stress fracture) and I'm guessing my Vit D levels are fine as I live in a sunny place!

When you said: Sure, you want to avoid exercises that emphasize bending the toe at push off, but elliptical and cycling, and swimming can normally be done safely (perhaps with a slight modification). does that mean after 1-3 months in a boot, or during the same period?  One physio has suggested to me deep water walking as a possible exercise.  Does that sound like too much foot bending to you?  (She's suggested it because I can't do much bike riding because of knee problem - bout 10 minutes is tops, and can't swim because of shoulder problem - yep, I'm a complicated case Emoji
Dr Blake's comment: There are 3 phases of Injury Rehabilitation--Immobilization, Re-Strengthening, and Return to Activity. You definitely need to be in the Immobilization Phase. The Removable Boot and Anti-Inflammatory measures should really calm your foot down. However, some foot strengthening and some cardio/core workouts are not only fine but crucial to a faster rehabilitation. You have to see the post entitled Good vs Bad Pain and memorize it. Keep the pain level between 0-2. Swim in the deep end of the pool if you can control the pain level, cycle 100 miles if the shoe or pedal position can be modified to avoid irritating the area consistently. 

 And finally, in response to your comment: You will learn this next year how to minimize the time of flareups, what activities pick on it the most (I purposely gave up golf with my back due to the torque, but have been able to play full court basketball with no problem), develop a relationship with a good orthotic maker, begin a lifetime of foot strengthening exercises, learn to select shoes that you do not pronate into, etc etc. A bunch of learning!!  Yes, I know what you mean, it is a life long project.  Unfotunately at times it feels like learning to adapt and compromise is neverending as I already have learned to manage chronic pain from ongoing back and shoulder problems.

Thanks very much for your advice and words of support in your reply on your blog.

Kind regards

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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.