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Wednesday, August 9, 2017

Big toe joint pain: Email Advice

Dear Dr. Blake,

I'm a relatively new fan of your blog, and am grateful for all of the information you provide - it's a godsend!

I'm writing this email as I contrast-bathe my right foot (multi-tasking!). I'll cut to the chase with my question, and then provide details below: what is the timeframe for reducing the inflammation that causes hallux limitus - is it a matter of weeks, months, years?

Here's my case: I'm a 53 yo woman, in otherwise excellent health. I developed pain along with a big "bump" on top of my foot, just at the base of my right big toe - this was over several months (probably last fall into spring). Not sure how it started.

I finally saw a podiatrist May 31 2017. From the examination, and subsequent xrays, he diagnosed hallux limitus (the xray result reads: "Moderate MTP arthrosis of great toe is present. No malalignment can be seen. Findings would be suggestive of hallux limitus or hallux rigidus. No other specific abnormality of the right foot can be seen.") He told me to take 500mg ibuprofen 2x/day for 10 days to see if that would reduce the inflammation; I could continue that for an additional 10 days before returning to get a cortisone injection. He also suggested that I use warm moist heat for 20 minutes several times a day.

I did about 15 days of high dose ibuprofen, and in the meantime discovered your blog. I'm not keen on getting a cortisone injection, and long term use of ibuprofen at that level seemed unadvisable, so around mid-June I began to follow your "top ten" list for hallux limitus: I started contrast bathing religiously (at least once daily, sometimes 3x a day); I started applying Voltaren 2x a day; I spica taped; I got some dancer's pads (although this caused me discomfort in my ankle and made me limp, so I discontinued that); I only wear comfortable, flat, soft shoes; I do the joint mobilization gently every day; and in general my pain level is 0-2 most of the time (unless I do a lot of walking - but if I soak my foot in an ice bath right after that brings the pain right down again).

It's been about 6 weeks of this regime, and while my pain level is way down, I still have a big old bump on top of my foot, and I still have very limited ROM (I can point my toe, but not flex it back).

How long can/should it take for the inflammation to start to subside?
Dr Blake's comment: Sounds like you have done a fine job with the inflammation. If you have the 0-2 pain level, you can gradually increase activities, but try to avoid excessive toe bend for the next 6 months. You may have entered a new phase of the hallux limitus and your joint will be somewhat more restricted. You can walk up tall mountains without bending that toe. Get some 1/4 inch adhesive felt from Use it to place a small pad behind the bump, and relace some shoes so there is minimal pressure on the bump. You can thin the 1/4 in half and make better dancer's padding. My blog is full of examples for this stuff. If we take the pressure away from the bump, and avoid excessive toe bending, and you ice massage the bump area twice a day for 5 minutes, we have to see what you can and can not do and still keep in the 0-2 pain level.

And: at what point might I want to go back and accept the offer of the cortisone injection (if at all)?
Dr Blake's comment: I would do a cortisone shot if the MRI shows no bone edema. It rarely shows that, so cortisone is rarely given. Your icing, voltaren patches, activity modification, shoe adjustments with cortisone masking the pain will be done better. We will make decisions better with a cortisone shot working. The cortisone is temporary if there is joint damage. If the joint got all jammed up, and there is no damage, the cortisone may be a miracle to get the joint in better shape. Basically, we do not know enough.

What signs of healing can I look for? And what might be signs that I should return to the dr for a re-diagnosis?
Dr Blake's comment: Consider an MRI to know what we are dealing with. Based on the MRI, which is usually the first of a few over the next year, we can really appreciate healing. With no MRI, we can still go by accomplishments, or benchmarks. Each month you should be able to do more. If not, the joint needs to be re-assessed. What could you do, and at what pain level, May first, then June first, then July, August, Sept. Are we reaching a plateau? Are we making steady progress? Do we have to make changes to get us back to 0-2? Is my activities improving? This is where the doc or PT can help move you along. Sure hopes this helps. Rich

I'm willing and ready to do rehab for a long haul, I just want to have a better sense of what I'm in for, and when/whether I should go back for additional medical intervention. (Esp since my podiatrist gave me the impression that 10 days on ibuprofen might do the trick...)

Thank you!


  1. Thank you for the response! I'm a little confused by your advice on the cortisone, but it sounds like continuing on my conservative approach will eventually yield results and get the inflammation down. Sounds like the time horizon is 6 mos to a year...I can work with that. I prefer to avoid the cortisone if I can achieve results without it. Thank you!! Wendy

  2. I hope you get another podiatrists opinion in person too. Shot- and ibuprofen-happy podiatrists are suspect to me...


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.