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Saturday, August 30, 2014

Hallux Limitus/Rigidus: Email Advice

Thank you for your wonderful website, which is a godsend! I hope you can guide me: I have been running with hallux rigidus (limitus) in both big toes for some 20 years, finishing 51 marathons. Over the years I have gotten a lot of orthotics custom-made, but none have brought relief to my left big toe. Recently, I have developed Ledderhose on the facia of both feet. Would you have any suggestions about orthotics which would accommodate my problem feet? I am really looking forward to your reply!


I forgot to mention that I have hallux valgus (left big toe) as well as hallux rigidus (both big toes) and Ledderhose (both feet), and some pain in the other toes of the left foot. Which orthotics would you recommend for running shoes ?

Dr Blake's comment: 
     First of all, congratulations on 51 marathons, quite a feat (47 more than me!!). Also, for those that do not know, Ledderhose is disease where the plantar fascia gets very scarred and thickened. Typically, Ledderhose can be injected with cortisone without fear of rupture due to the severe scarring, but I am sure there are exceptions. 

     When you are designing orthotics for a situation like this there are many factors to look at. Let us look at one at a time. 

  1. Hallux Limitus: Need enough of arch support and inversion to get the weight into the middle of the foot at push off. The padding in the metatarsal area should be to off weight the first metatarsal (dancer's padding). Occasionally the reverse needs to happen with padding under the first metatarsal to limit the motion (called "Morton's Extension). Also, how stiff should the forefoot be of the shoe? Should you use the New Balance 928 with a stiff rockerbottom sole? Should the orthotic be full length and stiff, like using a Sole OTC orthotic, and then making the forefoot of the device even stiffer. Should you use a carbon graphite plate under the orthotic to get your stiffness?
  2. Ledderhose: This is tricky with arch sensitivity. How much pressure can the arch take from an orthotic? Should cortisone be used to reduce the soreness before the orthotic is made? Do you need the arch support part of the orthotic or can you simply use a varus wedge to shift weight for the hallux limitus/big toe joint pain? 
So, these are all the ways you are experiment and begin to individualize the biomechanics for your unique situation. I hope it helps somewhat. Rich

Here is the patient's response:

Dear Rich,

Thanks for your reply. You hit the nail on the head: my problem is that stiff insoles hurt the Ledderhose (of the right foot), while other insoles don’t offer sufficient support and relief to the left rigid hallux. I’ve even tried a stiff (Langer) insole in my left shoe (with a cut-out under the first metatarsal, which mimics Morton’s extension) and a less stiff one in the right shoe: that worked for a couple of mid-long runs but I suspect wouldn’t be advisable, what with sending different signals to the brain, etc.

I’m now using dancer’s padding with fairly pliable orthotics in my Brooks Adrenaline (a shoe which has stood me in good stead over the years—and which I desert for Nike Air Zoom Elites only for the actual marathon races), but that does not offer as much relief as stiffer insoles do.

So I’ll take your advice and start experimenting, investing in a pair of New Balance 928s and in carbon graphite plates; I’m also going to try a real Morton’s extension.

I won’t give up until I’ve done my 100th marathon!

Thanks for your very welcome advice. May I keep you posted?
Dr Blake's comment: Defintely!! And good luck, one at a time. 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.