Yes, You Can Unfuse the Big Toe Joint: Interesting Blog

https://anika.com/blog/can-my-toe-fusion-be-unfused-we-have-answers/?fbclid=IwAR0zgVZJEwE_LWcSvUJ_Cw0jYHfz59cwlBOoA_Xbv3qK2F_BUVdcw_frBdE

I also encourage Hallux Rigidus sufferers to view facebook page on Hallux Rigidus

Can a Patient Walk Well and without Problems with Big Toe Joint Fusions for Hallux Rigidus

https://www.facebook.com/download/531737191640275/02_07_2017%20Gait%20Analysis%20of%20Foot%20Compensation%20After%20Arthrodesis%20of%20the%20First%20Metatarsophalangeal%20Joint.pdf?av=1568287145&eav=AfY8moMdRWZwme9PP23bk81Af93vGN1LoENbVVyR_LM05adSRvNRB_f8Ex6t6ZxQsjs&paipv=0&hash=AcoGJAvMX3oPGRywSfE&__cft__[0]=AZWVks2l-WYTD_dHpYlGF8p0otjFiDYKrVcnZMdtauES1JJfZDs8JEL8gwvjaZtsqMnrnuWaWP7Y9SVKu9m6sBfIsILpm-VnQbEq6gGutHwtTKv9tMA4BPFHWiTT2Ey2a32O4kqxJH38zRglc7QlmnXgzS31GyPE2lcrDMeaz9GkMQ&__tn__=H-R

Problems post Big Toe Joint Fusion: Email Advice

Dear Dr. Blake,

I was referred to you by Stephen Pribut (podiatrist in the Washington, DC. area).  He said you may be able to respond to my questions by email and offer suggestions for a course of action.

I am writing to request your opinion on the problems I am having with the fusion of my left big toe.  I know this is not an examination but I believe you can address a couple of specific questions I have described below.

In May 2017 I had my left big toe fused due to hallux rigidus.  Once I started trying to walk, I felt significant pain underneath the last joint of the big toe.  There is no pain at the MTP joint.  For the last 18 months, I have been trying to determine the cause of the pain with no success.  The surgeon says the fusion is okay. 

In June 2018, I got 2nd opinions.  I was told either the angle of the toe was fused too low or the hardware was to blame.  I didn't want to redo the fusion so I had the hardware removed.  This did not solve the problem.
Dr. Blake's comment: This is not uncommon, but a pesty complication where the big toe is not fused high enough so the end of the toe becomes the low point when pushing off and takes all your body weight. You can rebreak and refuse or design orthotics to off weight the point to distribute the force. Most choose the orthotic or padding option. 

I came across the chapter attached discussing complications of the fusion.  My symptoms mirror exactly the situation where the toe was fused too plantarflexed or too low.  If you look at the upper of the HOKA rocker shoe I've been wearing, it is evident that my midfoot to the 5th toe is bending over to the outside.  Then, as I walk, I pronate and roll over the foot to the inside trying to avoid the end of the toe.  I have a large callous on the side of the toe as a result.  I have tried but now realize I can not really feel the ball of my foot/MTP joint touch the ground.  So, when I toe off, all the force is on the end of the toe.  It looks like the xray shown in the chapter - Figure 2A and 2B, p117.

I would appreciate your comments on 2 items:

1. I had a gait analysis on November 19, 2018.  The graph is in the attachment while other data is copied below.  I believe the graph/image supports an over plantarflexion of the left big toe.  I know this is not a formal examination but please can you tell me what you see from the graph/image? Dr. Blake's comment: Yes, that is how it looks.  

I would note my right foot looks more normal to me even though I had some scar tissue excised on the 2nd and 3rd toes just 2 weeks ago.  It is little stiff but no pain like I experience with every step with my left foot.

2.  Noting the pronation of my left ankle, the physical therapist believes that might be a cause.  I have always had some pronation but I have never had pain under my toe until this fusion.  I believe the pronation is now exaggerated because the midfoot is rolling to the outside which it never did before.  So the ankle has to roll farther to the inside to get me over the toes.

The pt suggests a medial wedge.  I think this may make the midfoot problem worse.  What do you think?
Dr. Blake's comment: Yes, a medial wedge will just throw you out and mess everything up from more constant supination. Typically it is a balancing act of some lateral support so not to supinate at all, and some off weight-bearing padding on a full-length orthotic device to take pressure away from the point of pressure in the gait image. 

He taped the inside of my calf/heel as a test and that caused pain just below the knee on the inside.

All the modifications to shoes, orthotics, etc. to avoid the big toe only make foot mechanics worse, not better, in my opinion.
Dr. Blake's comment: You are on the right track. You need stability with weight spread out on the big toe, just not on the sore spot. After a fusion, the benefit is to have this stable big toe joint that is not painful and can accept all this weight. At least by theory. So, you want a stable orthotic that loads 90% of the big toe, not off weights the big toe. 

I would be most grateful for your opinion on these 2 matters.  It is looking like I will need to get the fusion redone.  I want to make that decision with the benefit of all the information I can obtain.  It is difficult when there will be opposing views.  My goal is to return to downhill skiing and hiking if I can.  Three years ago I was playing tennis too.  Now, I can't go for a walk because of the pain in the foot and related hip and lower back issues.

Thanking you in advance for your help, Good Luck!!

Dr. Blake's comment: 

I am just back from Hong Kong, visiting my son and his family so my response will be influenced by jet lag to some degree. First of all, thank you and Stephen for contacting me. The graph looks like the pressure from standing only with you having a high arch. Is it true,  and are there other graphs? Typically these problems do not need another surgery, so I am so sorry the hardware was removed. If the big toe was placed too far plantarflexed, and you can not bend the joint, you have to get orthotics that stabilize both sides of your foot and get Hoka shoes that roll. Typically you can build up the orthotic device under the big toe joint and the base of the hallux to even the pressure through that area. Most podiatrists can accomplish that. You can test that theory by getting 1/8th-inch adhesive felt from www.mooremedical.com and place something like a cluffy wedge on your foot (explained in my blog). The area on the toe that is hot should not have any covering. Please take this info and ask me other questions. Rich

Wednesday's Article of the Week: Gait Changes Post Big Toe Joint Fusion

So many of my patients with Hallux Rigidus do not like the thought of big toe joint fusion, and I share that thought. I have only two patients in my practice and they are doing well post surgery. I present this article abstract to help with pro/con list we all create when trying to choose between different treatments. I would still recommend joint fusion in only small instances, but when I do recommend the procedure articles like this help me feel better that the patient will do well afterwards.

Below are the foot x ray images of my patient who is doing very well with her big toe joint fusion. The hardware is scary, but she is stable, pain free, and comfortable walking. She is 2 years post fusion by our podiatrist Dr Remy Ardizzone. Dr Ardizzone is very skilled at cheilectomies (joint clean outs) and implants, but felt fusion due to the severe joint arthritis was the best option. My patient is happy with the results.

http://www.ncbi.nlm.nih.gov/pubmed/17296132?dopt=Abstract

Hallux Rigidus: Great Comments from patient after Joint Fusion

Male, early 40s and I take exception with opinions above steering people away from certain treatment. I started in orthotics for a while, then bilateral chielectomy in 1999 for Hallux Limitus, eventually progressed to minor Hallux Rigidus. Again, chielectomy got me by for 2 years before little was left for joint space, along with arthritic bone surfaces.

Tried arthroplasty on left instead of fusion. It failed due to quick return to arthritic bone surface that shredded the tissue. Fused shortly after, then once that was stable enough, fused the right at the end of 2012.

This year I've had a sesamoid removed in the right, opted to increase the angle of the fusion in left due to some hip/back pain and general discomfort of the toe in shoes. I'm weaning out of the walking boot now, but showing signs of sesamoiditis already. My guess is I'll just have that removed and not drag out the process any further.


I've had 9 surgeries, and I will state with extreme confidence that if you take the usual 7-10 initial days of recovery IN BED with foot up, you'll be far better off. Toughing it out or playing hero by going back to work in 3 days, slows healing and greatly increases risk of infection and injury of vulnerable foot... won't fool your doc at all either. They know when you push it.

I was a U.S. Marine... I can push myself physically and mentally. But I know enough NOT to push. What's the benefit of pushing? None... except maybe to your employer. It's NEVER acceptable for your health to be less than top priority for you and even your employer when you end up in surgery again... less productivity long-term, etc. Of the 7 my current surgeon has done, he called me out on #4. I went back to work at 6 days, 3 days sooner than any other and he knew it before I said a word. 

I have no hesitation about surgery if needed. I have a fantastic surgeon, ask every question I can think of and accept answers I may not want to hear. Consider your situation honestly and do what is recommended by the doctors. The recommendations aren't guesswork. 

I suggest the opposite of a gal above. DO consider fusion or other procedures, but only a good fit for your condition, your surgeon's preferred course and all post-op aspects of the process. Ask about what's next after surgery. What option are if something doesn't go as planned. It can and does happen, and having a plan you and your doc agree upon is vital. Don't focus on future problems, but do talk about the possibility. Non-union of a fusion after you went out golfing on day 4 is on you and if you have a plan for complications, everyone moves forward. My surgeon actually had such a patient. Next initial post-op visit, I walked in using a 3-iron as a mock cane. :)

Oh, and shoes are often a question here, as well. For me, hands-down, New Balance with plenty of width. Do not skimp on width! You'll get used to and treasure it very quickly. Even then, the exact same model/size can differ between pairs. Finding what works consistently does take time, and likely won't be a $29 pair of cheapo shoes. Pain relief is worth time and money for me, though. 

The local New Balance store lets me mix and match from boxes of same size/model and gives me 7 days to walk in them because they know I'll be back next time. Even a 1/8" tilt difference due to slight tweak during manufacturing of two otherwise identical shoes makes all the difference in knee/hip/back soreness. As shoes age, they stretch in different places, as well. Do not discount this aspect of your treatment and recovery... you do so at your peril.

I'm a lurker, but a fan, Dr. Blake... keep up the great work, and your participation in discussions here is valued far more than you realize! Without it, the site is just a place for you to opine and others to talk about you, usually in the negative, benefiting nobody. Because of your willingness to be involved, I have sent two your way, one a happy cured patient, the other currnet and they are very pleased, as well.

Big Toe Joint Fusion: Email Advice

Hello Dr. Blake,

     I am in my 8th week of recovery from a fusion of my great toe and struggling with pain that I am not sure is related to the original injury or surgery.

2 Slightly Different Views of the Same Right Big Toe 

     Pain occurs mostly on the bottom ball and feels like fire when walking.When my foot is extended (especially when laying in bed) the pain runs along the arch and then to the outside of my calf causing it to fall asleep.   Dr Blake's comment: definitely nerve pain with nerve tension.

     Doctor hit it with cortisone and it is not helping. Dr Blake's comment: nerve pain may and may not respond to cortisone, since it only helps the inflammation involved. 

 My doctor is great...it is just that I will not be able to see him until end of week and I wanted another eye on the x-ray. I have attached photo of x-ray from the 2nd week after surgery as that is all I have with me. Does this sound like sesamoid trauma and is that something I should have my doctor explore? Do you see any indication in the x-ray? Thanks for the blog and for responding with any advice.

Dr Blake's comment: most likely the nerves that run under the fusion area that extend under the ball of the foot and into the arch and then up the leg are irritated. Why they are irritated is what needs to be investigated. The fibular sesamoid looks irregular, but that may or may not be something. The Hallux (Big Toe) looks like it was broken as part of the procedure, so is it stable yet? If not, the healing fracture or healing fusion may be producing enough swelling that the nerves in the area are being stressed. A CT scan may be necessary to analyze the bone healing. Delayed healing of fusions is very common and just needs more time to immobilize. 
     Treat the nerve pain with your own relative rest, icing of the area, crutches if needed, etc. Since you do not want the nerve pain to get out of control, and before you know what is going on, create the pain free environment as best as possible. Sure hope this helps you. Rich Blake