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Saturday, March 16, 2019

Hallux Limitus: Email Advice

Hi Dr. Blake -

I stumbled onto your blog while searching for information on hallux limitus, which has been suggested to be by a podiatrist and PT. I'm a 33 year old man, in general good health and consider myself to be an active person.
Here's a brief background around the hallux limitus:
  1. I started walking about 10k steps per day in October 2017. (Roughly double what I was doing before Dr. Blake's comment: That total is one of my mantras for life. 
  2. In January 2018 (4 months later), I began a transition to moccasin-style (SoftStar) shoes with CorrectToes silicone toe spacers.
    • Both of these were in hopes of improving knee and hip pain that doesn't allow me to run and shows up while hiking long distances, but that wasn't a problem during everyday walking.
    • About 10 years ago, a PT told me I had "runners knee", "patellofemoral syndrome" or "IT band syndrome" causing pain in my right knee that required me to stop a training program for a marathon. This diagnosis was when I got interested in minimalist shoes and other 'alternative' approaches, and why I began this transition in January 2018.
  3. In March 2018 (about 2 months into the footwear transition) - during one of my walks I had a sharp pain develop quickly (over the span of probably one minute) in my right big toe. It was bad enough that I had to stop walking and get a ride home.
    • That evening I noticed some bruising that wrapped basically from the underside of the proximal phalanx to the right side of the IP joint on my right big toe. Not sure exactly how to explain this, but it looked like bruising that originated from inside the toe somehow - i.e., not from some kind of trauma. Dr. Blake's comment: I do not know how much you pronate, which could be the issue, or just the correct toes pulling on the ligaments too much with that amount of walking. I tend to use correct toes just around the house, at least for several months until you get used to them. They are powerful tools, but of course you probably had no guidance. 
  4. My physician ordered x-rays - which he said just showed soft tissue swelling under the joint but nothing specific. Dr. Blake's comment: Good start. 
  5. In April 2018 - A podiatrist examined me and suggested I had Hallux Limitus. Dr. Blake's comment: Is it functional or structural, or a combination of both. What were the degrees that they measured? Normal big toe dorsiflexion (upward bend) is 75 to 90 degrees and Hallux Limitus is between 30-60. 
    • His recommendations were: orthotic inserts, shoes with a 1/2 to 1 inch heel, and shoes with a rigid midsole. Dr. Blake's comment: With hallux limitus, all three of those things can help or hurt based on several factors. If you get them, and they bother you disregard. Try everything together, and also separate to see what the effect is on the big toe. 
    • I ended up using Vasyli Dananberg First Ray Orthotics, which claim to help with hallux limitus by having a 1st MPJ cutout. Dr. Blake's comment: These are to increase the motion in the big toe joint, so why a rigid shoe? Of course there are times to limit the motion, and times to free up the motion. Do the self mobilization video a couple of times a day to see if that helps.
    • And I moved to walking primarily in hiking boots which met the podiatrist's suggestions.
    • The footwear and orthotics didn't really help - and I developed gait compensations around the toe pain that caused me to develop some hip and knee pain just from everyday walking. Dr. Blake's comment: It can just be the timing of the treatments. If the joint is sore, the treatments may best be spica taping, no orthotics to increase motion, and stiff shoes. You can also get Hoka One One shoes for a while to limit the toe motion but allow walking. 
    • In June 2018 - I saw a PT to help me with some stretching and exercises.
    • This seemed to help a bit, though I couldn't resume my 10k steps walking program. Dr. Blake's comment: Do you think it is weight bearing pressure causing the pain (then dancer's padding is apropriate) or the bend of the big toe joint (then spica taping, rigid shoes like Hoka One One). Both seem would be made worse with an elevated heel unless it supinates you so your weight is more lateral near the 4th or 5th toes. 
    • I kind of gave up at this point in frustration.In August, I realized I had taken a couple long hikes with no pain or toe problems - so I cautiously started my 10k daily steps program again.Over the 5 months since then, I've continued the walking. I have had some pain, but never to the point where I had to stop walking. And I could manage things with achilles tendon stretching, dorsiflexion exercises, and general funny business with ankle movements.But now in the last couple weeks, the big toe pain has come back big time and I've had to stop my walking program.Dr Blake's comment:  I am glad you mentioned achilles flexibility, since tight achilles puts extra load on the metatarsals and is helped with stretching. Joint pain can come and go. Now is the time to see if Hoka One One, spica taping, dancer's padding, and ice 10 minutes three times a day will help. Do you have a walking boot to maximally rest it? 

I have a couple goals:
  • Keep up my walking.
  • (Stretch goal) Start running again.
  • Importantly: Don't harm my joints in a way that will be debilitating later.

I'm open to a variety of interventions to reach these goals - but in general, I would prefer things that involve strength, flexibility or gait improvements rather than footwear, orthotic or surgical solutions.

Your blog and youtube page seem to have a lot of really good information about hallux limitus - so I figured I would reach out and see if you have some suggestions for me.

I also see that you're in San Francisco - I live in Oakland and I would be interested in scheduling a visit if you thought that could be productive.


Thanks so much - for your excellent information online, and for reading this (Dr. Blake's comment: only read to this comment, no farther!!LOL) far!

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.