Adding Stiffness to the Front of an Orthotic Device

https://jmsplastics.com/product/j-suede/

     The image above was taken after I applied a very thin piece of suede leather. This is stretched before tacking down to stiffen the bend across the metatarsal heads. This is a very useful technique when trying to treat metatarsalgia symptoms, Morton's neuroma symptoms, hallux limitus and rigidus symptoms, and all without adding alot of bulk in that painful area. 

Hallux LImitus: Can I Avoid Orthotics?: Email Advice

Hello Dr. Blake, 
I came across your article  “ Treating a runner with Hallux Limitus who does not want to stop running.” while searching online for advice to keep running after being diagnosed with Hallux Limitus with bone spurs. 
Is it possible to keep running with this diagnosis without orthotics?     I run in Brooks Ghost and put in about 15 miles/ week. Can I run in my Brooks with the medium gel toe separator and avoid additional injury to the joint ? 

Any advice is greatly appreciated. 

Thanks,

Dr. Blake's Response:

Hallux limitus is a slow gradual progressive degenerative process when there are spurs. I have had runners for 30 plus years continue running, but there is no magic cure. The goals are to protect the joint with decreasing stress somehow, never run with pain over 2, and especially no limping. Running itself is very natural for the body building strength in muscles and bone, and has a huge emotional aspect. It is part of any athletic participation program, and I think vital to people’s health. 

    The goal in the short term is to continue running your 15 miles per week, while you build a program to keep the pain level between 0-2. Orthotics themselves can both hurt and help, so typically not my #1treatment unless you are a moderate to severe pronator. Pronation jams the big toe joint into the ground increasing the stress. The orthotics have to be full length and require expert attention since the rigidity under the big toe joint in a full length orthotic device may be too much pressure to the joint and have to be modified.
    So, in achieving this 0-2 pain level, without going over the physics of each one, include the following which predictably decrease stress on the big toe joint: spica taping, dancer’s padding, hoka running shoes with rocker bottoms, cluffy wedges, arch supports, Morton’s extensions, shoes with great forefoot cushion like the Ghost, etc. 
    My blog talks about this individual treatment options. I hope this makes sense. Rich 

Hallux Limitus/Hallux Rigidus: Conservative Thoughts

Let us start the discussion on avoiding surgery for Hallux Rigidus as our first option. Let's try conservative care for awhile. Here is my original Blog Post way back in 2010 on this subject.

 

https://www.drblakeshealingsole.com/2010/08/hallux-rigidus-surgery-or-no-surgery.html?showComment=1587046318374

 

Here are 2 PTs discussing mobilization of the joint. I typically do not recommend putting a rigid hard device under the toe that hurts initially, and I typically avoid the standard dorsiflexion and plantarflexion motions, but it is okay to see how it feels.

https://youtu.be/xORPFVXv6_M

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.

https://youtu.be/Z21MtkhW7e0

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.

https://youtu.be/FBTeWbdGrzs

• 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. 

https://youtu.be/l_4HESXCG40

• 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,

And the Patient Responds:

Thank you for the great responses. To answer the questions you asked on the blog:

 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. 

Neither my podiatrist or PT mentioned checking for this. They also did not take explicit measurements of the dorsiflexion, just a general examination. Is there a method to examine and get clear answers to both which type and what the degrees of dorsiflexion are?
Dr. Blake's comment: The first video above shows how to measure joint motion, and the link below shows Dr. Sander's video on functional hallux limitus.
http://www.drblakeshealingsole.com/2015/02/functional-hallux-limitus-meaning-and.html

 [Regarding Vasyli Dananberg First Ray Orthotics] 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.

I selected these orthotics after some research online. I don't think I fully understood there was a difference between functional and structural hallux limitus. So if I'm thinking about shoe/orthotic pairings - would you suggest that I stick with standard orthotics on a rigid shoe, and the cutout orthotics with a more flexible shoe? And just test how things feel with one or the other.
Dr Blake's comment: That may be best, but right now go with feel. It may be the opposite for you, in flexible shoes you need more orthotic restriction, and with rigid shoes you need more orthotic motion. 

 Do you think it is weight bearing pressure causing the pain (then dancer's padding is appropriate) or the bend of the big toe joint (then spica taping, rigid shoes like Hoka One One). Both seemingly would be made worse with an elevated heel unless it supinates you so your weight is more lateral near the 4th or 5th toes. 

Hard to say if it's weight bearing pressure or from bending the joint. If I had to get specific on the pain location, I'd say it's on the underside of the right big toe between the MPJ and the IPJ. And when it gets bad, the joint (I think the IPJ) tends to click or pop for awhile until it heals up.

 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? 

Much appreciated, I'll try these things. How much risk is there of permanent damage if I continue to walk when the pain is intermittent and not debilitating? Dr. Blake's comment: None, if you have a degenerative process, it will slowly get worse, and you must try to manage the symptoms with as active life as you can. If this is not a degenerative process, that type of pain is not damaging only a nuisance (definitely frustrating). Good luck Rich

Thanks again.

Hallux Limitus: Email Advice

Hi Dr. Blake,

I am a 34-year-old runner with Hallux Limitus and am hoping that you could help me. I have seen two podiatrists in my area (Lynchburg, VA) and they both have told me to just stop running. I run 20-25 miles per week (I did do a couple of 50k trail races last year but found that the steep up and down trails in the mountains irritated my toe). I am okay with not running these long races if it means that it will make my condition worse but I would love to be able to continue to run for many years.
Dr. Blake's comment: Hallux Limitus is either functional (which can be totally reversed with some arch support and dancer's padding to off weight), structural (meaning some degenerative process which will get worse and you still try to keep your pain between 0-2 and experiment with off-weighting and arch support), and structural and functional combined. If your big toe joints have some structural damage (typically diagnosed by x-ray or MRI), I would still run as long as you can in that 0-2 pain level. If long races increase pain, then you must avoid, but if 5-10 miles is fine, it is actually better for joints to have a pain-free high-level loading for cartilage nourishment.  

I do not want to ignore this and make it worse but rather run responsibly.

I have been running in Hoka Bondi's but I'm finding with the orthotics inserts a PT suggested I use (she has said I can continue to run), that the toe box is too small. I did try on Brooks Glycerin and Altra Paradigms and both shoes felt great but I'm not sure if they're great for this condition.

Dr. Blake's comment: There are some many factors that jam up the big toe joint, so it is experiment time for you. Definitely, find the wider Hoka One One shoes, they are out there. Hoka should be a great shoe for some of your running. Also, get a medium gel toe separator to see how holding the big toe in the center of its joint makes you feel while running. I love Brooks Addiction or Beast for the varus cant off the big toe, but of course, we do not want you to roll your ankle. Definitely, you want to see if those shoes, along with a 1/8th-inch dancer's pad to keep the weight in the center of your foot at push off. The zero drop shoes are good for metatarsal pain, but not good usually for hallux limitus. They put you back on your heels more, for pain reduction, but in most make it harder to push off. Some of my patients push off hard, and others hardly at all. 

Do you have any suggestions that will keep me running without irritating my toe or cause this condition to progress? Above If I take care of it and am cautious, does this condition always get worse? I would rather be proactive now than later.
Dr. Blake's comment: Have some weight bearing xrays taken of your feet, take photos of each frame, and send. Again, if it is primarily structural, you will have more work to do keeping in the 0-2 pain range. You would want to re-x-ray in 2 years and see what is happening. Arthritis is made worse faster by not using it, then if you can use in a pain-free environment. Look up the nutritional theory of cartilage development. Yes, if you have arthritis, and you push through pain, you will speed up the need to have joint replacement surgery. 

Also, do you know of anyone in the Central Virginia area that is up to date on this condition? 

Dr. Blake's comment: Call Richie and Company, an orthotic lab in Charlottesville, and ask who are the good biomechanics people in your area. They would know. Use my name. The owner is Brett Richey. 

Thanks so much. This whole thing has been frustrating and disheartening, to say the least. Also, I attached a picture of my most recent xray.

Dr. Blake's comment: The x-rays were poor quality and not sure if weight bearing. Have AP, Oblique, Lateral, and Plantar Axial xrays taken of both feet at some time and send me 8 individual photos. Please make sure they are weight bearing. Good Luck, Rich

Thanks again,