Thursday's Orthotic Discussion of the Week: First Toe Stability aid with Budin Splints

I love Budin Splints to stabilize the 2nd metatarsal phalangeal joint. In this images, I am failing at my goal. I need to get the 2nd metatarsal down more, so that when the patient stands, the second acts as a stabilizing force against the first. If the second can be brought down with a tighter fit, or my changing to a double Budin Splint, I will have achieved a more stable first ray. The more stable this medial column, the more stability and comfort there will be in the body.

Budin Splint Modifications for Sore Toes/Metatarsals

Hi Dr. Blake and I hope you are staying dry!

You asked that I email you with how I’m doing. We met on Tuesday, November 6^th regarding pain on my right foot at the base of the second toe.  You prescribed a pad with an elastic loop to wear around the second toe along with some stretching and icing.

It’s now been 11 days and I can’t say I’m felling much different. The pad is irritating to wear with sneakers or boots because when I slip my foot into the shoe, the elastic loop gets pulled down and irritates the skin at the base of the toe. Sometimes I have to take it off for a while.

 I find that when I wear my clogs with an open heel, however, it is much more comfortable.  I don’t usually wear clogs but it’s the only shoe that I can wear the pad pretty much all day without discomfort. I’ve been pretty religious about wearing the pad regardless.

I’ve been bad about the icing. I’ve only iced twice since seeing you.

I do the stretches but not daily.

So I haven’t been the perfect patient.

What do you suggest?

Thank you.

Dr Blake's Response: 

Hey Alicia (name change), Thanks for the update. Try getting a digital gel pad at the Sports Shop to put under the splint. It is a long finger looking structure, that you can cut into 3rds to place over the one toe. I have also attached the link to Silipos company that makes these things.  Then you can put the splint on tighter even. You can also use paper tape on the top of your foot to tape the splint down so it will move less. Attached is the note I wrote. Definitely ice twice daily, since the pain you are feeling is inflammation. Remember to stretch and perhaps buy some Yoga Toes so that we can begin to introduce them. Sure hope this helps. Rich PS If the icing does not bring down the inflammation along, then we can have you ice and go to PT. They would love to work on your foot. 

Budin Splint is a powerful stabilizer of the toe joints. When the elastic band is irritative, a digital gel pad can be used initially over the toe, or just tape to hold down the band and prevent it from moving. 

Alicia is a return patient I have not seen for about 4 years. Nancy has pain in her right foot and second toe area for about 6 months. Her pain level on a scale of 0 to 10 is about 4 or 5. She is taking some Advil for the pain. Has 2 pairs of orthotics which both have reverse Morton's extensions made by Dr. David Hannaford. She is a 59-year-old. She is 5 feet, 128 pounds. Her activities that she likes are West Coast Swing, water aerobics, Zumba and dance aerobics. She would like to enjoy them without discomfort are her main goals.

SHE HAS NO KNOWN DRUG ALLERGIES.

Medicines she takes a regular basis include
1. Valtrex.
2. Calcium.
3. Vitamin C.
4. Vitamin D.
5. DHA.

She has had no past hospitalizations or surgery. She is on no special diet.

On my examination, I found someone who had pain in the 2nd metatarsophalangeal joint plantarly. It is sore on maximum plantar flexion of the joint, not dorsiflexion. She has full range of motion. There is no evidence of instability. She has always had a short second toe and I think that short second toe may be raising up just a little bit or the 1st and 3rd toes may be going under it. In either case it would trap the second metatarsal head against the ground and cause irritation. If you couple that with her reverse Morton's or dancer's pad, that puts the weight off the first and onto the second, so as part of her treatment I reduced the padding under the 2nd metatarsal head.

Alicia's 2nd toe is much like this. When the toe is being held up in the air by being above other toes, and can not physically get down to it's normal level, pain develops under the metatarsal toe joint. The pressure at push off stays too long in the one place. The splint is designed to pull the toe down into more normal alignment. 

DIAGNOSES:
1. Capsulitis symptoms, right 2nd metatarsophalangeal joint, 726.90.
2. Right hammertoe deformity, 735.4.

PLAN: So today orthotic devices were evaluated and on the right side the area under the 2nd metatarsal head of the reverse Morton's extension was removed. I encouraged her to ice twice a day, encouraged her to stretch the toe in a plantigrade direction without pain. I may go to YogaToes once it is less painful. I gave her a prescription for 2 Budin splints and this will be designed to hold the toe down. She is advised that she can easily adjust the bottom if there is any pressure.

http://www.silipos.com/products/orthopedics/Digital-Care

Chronic Metatarsal Pain in a Runner

Hi Dr. Blake,

I saw you about a month ago.  I have chronic ball of foot pain (had been present for 3 months) that although lessening is still stubbornly persisting.  The budin splint you suggested I get has helped.

Budin Splint with Metatarsal Pad attached to limit motion and re-distribute weight around the 2nd Metatarsal.

  The pain is has "moved" and is now below my second metatarsal.  I've been running on it 3 days a week and this definitely aggravates it.    Do you think the Neuro-eze cream might help me?

Do you think that cortizone could help (oral or injection)?  I would like to keep training.  

I will make an appointment to see you again if you think it would be beneficial.

Thanks in advance for any comments/advice. Tom

Tom,

     Thanks for the email followup. Neuro-Eze may help if the symptoms are neurological. Probably more inflammatory. I could give you a Rx for Voltaren Gel to massage in 3 times daily. I will leave with my asst Kathy. Call her Monday with the pharmacy number.

     If the Budin Splint is working, tighten it alittle each week. 

 Definitely continue to ice massage for 5 minutes three times daily. Stay away from cortisone since we are probably dealing with a slightly injured ligament and cortisone can weaken it further.Come back after 2 weeks with the Voltaren gel and bring in your running shoes. When you say that the running aggravates it are you back to the same level of soreness when you run again? Very important, and no limping. Read my blog post on Good Pain vs Bad Pain to make sure you are staying in the Good Pain part. Hope this helps.And, it is normally great when the pain begins to move, as the original problem is being isolated by the treatment prescribed. Rich

Hi Rich,

Thanks so much for your prompt response.  It means alot to me!  I will call Kathy in the morning for the Valtaren gel.  I tightened the splint today and felt some more relief so I think that is a good sign.   The soreness after I run is managable and does not affect my gait and definitely no limping or anything like that.   It's very stubborn though!   I'm trying to balance the running with cross training and I'm being as conservative as I can without losing my fitness.   I will review your good pain bad pain post.

Thanks again.

Toe Pain: Help with Budin Splints (email advice)

`Budin Toe Splint 1 ToeEmail from 10/25/10
Hi Dr. Blake:

When I saw you last week, we talked about using the Budin Splint, and I am getting some minor relief, but I suspect it will take some time. As you will remember I’m having pain on the third toe/metatarsal. Currently I’m using the Budin splint on that toe. But you also had them give me a double splint to use on the 2nd and 4th digits. I’m unsure as to when to use that – in place of the single budin splint eventually or alternating between the two?

Thanks.

Doug

Hey Doug, Thanks for the question. The picture above is a Budin Splint for the 2nd or 3rd toe. For pain in the 2nd or 3rd toes, patients have experimented with the loop over the 2nd alone (even for a 3rd toe problem), over the 3rd toe alone (even for a 2nd toe problem), or opening up the loop for buddy taping the 2nd and 3rd toes together. One of these 3 options should feel the best if you experiment for a week or so. Then try every other day with the double loop over the 2nd and 4th toes (even for a 3rd toe problem, and even though the packaging has the loops over the 2nd and 3rd toes. If you find one way that helps the most, go for it. If 2 ways seem equally helpful, then I would alternate ways every other day to put varying stresses on your foot. Good Luck. Rich
Also see one of the original posts on this subject.
http://www.drblakeshealingsole.com/2010/04/pain-in-front-of-foot-possible-help.html

Hammertoes and Metatarsalgia: Possible Help with Budin Splint

Dr. Jill's (Budin) Hammertoe SplintPedifix Toe Straightener #P55

If you develop pain in the front of your foot (toes or metatarsals), one of the most successful treatment modalities is a Budin Splint. It should be initially worn very loosely around the toe. It is worn walking, not sleeping, and can immobilize the toes enough to rest the injured area. Normally, combining a Budin Splint, sometimes called a Single Loop Hammertoe Regulator, with two to five times daily icing can make the symptoms diminish significantly. See the post on icing. The loop that goes over the toe can be used on the toe that seems to be the most painful, or connected with the metatarsal that seems to be the most painful, or on the toe next to it (although not the big toe), or over both toes by opening up the loop wider. These splints can be bought at many locations including Footsmart.com and mooremedical.com. After tightening the elastic band to comfort, cut off any extra material on the under surface of the splint that is not under the pad, and then use tape (any kind) to secure the band to the under surface. The splint should never be worn if it increases pain in any area.

They are commonly used in enclosed shoes, or in socks around the house, to prevent or slow down the development of hammertoes. The photo above also shows an additional metatarsal pad (purchased from www.Hapad.com) for extra metatarsal support. They are an excellent post hammertoe surgery splint worn for up to 2 years. If the splint slips around alittle since it initially may need to be on loose, place a small piece of tape on the elastic band attaching the band to the skin on top of the toe. Golden Rule of Foot: Place the Budin Splint as far back onto the toe, away from the toenail, as possible. The splint itself should never feel like it pulls the front of the toe downward which could cause a hammertoe. The underlying pad is one size fits all so feel free to trim the size down if it cuts into you or interferes with your orthotic device. You should be able to make it work. If you start out real loose for comfort, once a week slightly tighten the band an extra 1 mm (slightly). If you are wearing it for pain, wear it 2 months longer after pain subsides.

Another type of splint has 2 loops, a double loop hammertoe regulator.Budin Toe Splint - Double Toe - Model 65065 I do not like how it pushes the two and third toes apart, so I tell patients to place on the 2nd and 4th toes. The double loop can be tried if only partial success is achieved with the varietions above of the single loop. I sure hope you like these products.