Hallux Limitus/Rigidus Restriction vs. Motion

Hello Dr. Blake

If I don't bother you I would like to ask you two questions related to your post from your blog "Hallux Limitus and Hallux Rigidus: When do we allow Motion and When do we Restrict":

http://www.drblakeshealingsole.com/2018/03/hallux-limitus-and-hallux-rigidus-when.html

-are you using an entire (supporting the entire forefoot) or Morton's type extension of the flat carbon graphite plate?

Dr. Blake's comment:   I have used either. It seems that 2 stores near me have the plates with the full foot stiffness. So it has been easy for patients to start with that. If it seems that is too much stiffness with irritation somewhere (metatarsals, ankles, knees in particular) from such radical restriction of motion, then I have them get the plate that is flat but has only a hallux extension for Morton's restriction. Again, I typically am going looking for a short-term restriction of motion when it is needed, with a return to motion when possible. 

-how do you choose the stiffness/flexibility or the thickness of the plate? 

Dr. Blake's comment: I am sure there is more sophistication in the process then what I know. I use the one from Otto Bock and have the patient simply buy their size. They are really stiff. Mine are stiff (firm) and flat (since used under the orthotic device). I guess I could go stiffer if it was not doing the job for a big guy. I love the spica taping at this time of restriction also. 

https://professionals.ottobockus.com/Orthotics/Bracing-Supports/Foot-and-Ankle/Carbon-Foot-Plates/c/4032

I will write these questions on your blog also!

Many thanks for your kindness,

Sincerely,

Hallux Limitus/Rigidus: Email Advice

Hi Doctor Blake,

I'm  desperate to find some pain relief for my big toes and your website offered such excellent advice to others I'd thought I'd seek your advice. I work in the movement field as a Pilates instructor and it's been devastating to be hobbled like this. I'm assuming I have hallux limitus since I have lost a lot of range of motion in my big toes in the last 2 years although if I think back, my feet started showing signs of what I though were bunions at least 5 years ago or more.When that happened I started wearing toe spacers religiously and trying to strengthen my big toe abductors. That didn't stop the progression of what was to come.

2 years ago both big toes suddenly seized up and were unable to extend at all! I have no idea what set this off-perhaps the fact I was doing a lot of walking in minimalist shoes at the time (which I tried because all my old shoes such as Keens were hurting my feet and only the flexible minimalist soles were comfortable! ) Maybe because I was doing a lot of exercises  kneeling on my shins with my toes tucked under (I can't even imagine doing that now!)  

I had to wear closed Birkenstock clogs to even walk to the subway when the toes first seized up. I used to walk easily 2 hours  a day to get to work and back. And suddenly I could barely walk-when this first started I even had to wear Birkenstock sandals indoors but since then luckily I can walk indoors in bare feet with small steps. The pain is both with toe extension at push off in walking (a tiny bit of pain in passive extension but not much)  but there is also a feeling like I'm walking over a hard lump on the bottom of the ball of the big toe. In fact at first I thought I had done something to my sesamoids.

I recently was so desperate that I even bought expensive Finn rocker shoes and those don't seem to help-I can still feel the right big  toe at pushoff.  I've bought an infrared light to reduce the inflammation, take Epsom salt baths which help somewhat, I pull gently on the big toes with the movements you've shown in one of your videos, and I take the toe passively through extension (which oddly doesn't hurt-it's painful mainly in weight bearing). All in all, a full time job. 

I also suspect that the way I walk has exasperated or even caused this issue since I walk with my big toe extensors being excessively active and I always poked holes in the tops of my shoes with my toes. I am willing to come to see you if necessary despite the travel.  If you have any advice I'd be so grateful since this has affected my quality of life. I fear this condition will only get worse so will do whatever it takes to improve it.

I'm including some recent xrays:

Right foot showing signs of big toe joint arthritis with spurring

Both feet showing top of the big toe joint spurring and right side sesamoid irregularity

Finding:
BOTH FEET:
INDICATION: Pain
Moderate to severe osteoarthritis of the first MTP joints is demonstrated bilaterally. No soft tissue calcification present.
IMPRESSION: Osteoarthritis.
DICTATED BUT NOT READ

Dr Blake's response: Thank you so very much for emailing. The right foot looks more painful, is it not? At least, the right side has less motion, or does it? Here is a link to my basic post on hallux limitus treatment. 

http://www.drblakeshealingsole.com/2014/12/hallux-limitusrigidus-top-10-initial.html

This is one of the original blog posts in 2014 that may help. 

  Hallux Rigidus means severe wear and tear on the big toe joint. The cartilage is tired, beat-up, and aggravated. The normal motion of the joint is significantly restricted, so attempts to move the joint normally can produce mild to severe pain. There is a lesser version of this called Hallux Limitus, which has significantly more motion, and a different treatment protocol.

     Hallux Rigidus develops over many years, with sometimes smoldering pain episodes, and may never really bother the patient. The joint is actually self-fusing, and getting less vulnerable. I had a great runner as a patient once that was having smoldering symptoms with severe advanced Hallux Rigidus. Luckily he ignored the surgeons, following simple conservative advice, and then proceeded to set a Guiness World Record for 6 marathons in 6 months all under 2 hours and 20 minutes!!

     But, some patients with Hallux Rigidus are not so charmed. They do something, quite ordinary usually, that develops moderate to severe pain. And they have trouble turning off that pain with self methods, x rays taken by the first doctor show the severe arthritis, and surgery is recommended. I maintain that Hallux Rigidus should be treated as a sore joint and nothing else. How do you get a sore joint calmed down? Usually, immobilization to rest the joint, shoes and orthotic devices to limit the big toe joint motion, taping to limit the toe motion, and then pile on the anti-inflammatory measures---icing, contrasts, meds, physical therapy, flector patches, topicals, accupuncture, and injections.

     The treatment of Hallux Rigidus is then divided into 2 columns--immobilization and anti-inflammatory. I challenge the doctors, physical therapists, and other health care providers to do all you can to calm the joint down and get it comfortable, even if this means 3 months in a removable cast (last resort). Once the joint is calmed down, and pain is gone, gradually increase activities pain free. See what it takes to stay pain free. See if there is any disability the patient does not want to live with, that you can guarantee with reasonable degree, would be removed if you did surgery.

     Let us say that you get the joint calmed down, but every time you try to run, the joint flares up. And you want to run, too young to give it up and you are willing to consider surgery. Xrays will show a bad joint with many bone spurs. There is no good surgery with Hallux Rigidus, so if I needed it, I would follow the KISS principle (see separate post). I follow the same thought process as with knees--cleanup with meniscus tears, more cleanup, a third cleanout when needed, a parital knee replacement when needed, and a total knee replacement when needed, and hopefully every surgery is the last surgery. So, with Hallux Rigidus, I recommend a joint cleanout (called arthroplasty or cheilectomy--try pronouncing those), perhaps another joint cleanout, a total replacement, another total replacement, and then a lot of deep thought before joint fusion is considered. Golden Rule of Foot: With Hallux Rigidus, Joint Fusion should be the last resort. 

So, if we make you a checklist for right now:

1. You need to create that 0-2 pain level by removable boot, hike and bike shoe, Hoka One One with orthotic/dancer's padding/spica taping and some daily anti-inflammatory measures.
2. This is so devastating that getting an MRI at least on the worst side, and you could send me a copy. 
3. Find out if you have any bone issues (get bone density test and Vit D blood level).

Hope this gets us started!! Rich

Hallux Limitus Discussion: Dancer's Padding or Reverse Morton's Extensions

​Dear Dr. Blake,

     I am a senior podiatry student. I was just reading one of your blog posts (Sesamoid Fractures: Advice when not healing well) and I have a couple of questions I was hoping you could clarify for me.

     My questions actually have to do more with hallux limitus. I have been trying to understand the difference between offloading the 1st MPJ with a dancer's pad for conditions such as sesamoiditis versus using a reverse mortons extension for a hallux limitus. Essentially they seem to be the same pad? But how could one be offloading and relieving pressure while the other one is increasing plantarflexion of the 1st MPJ (and I assume that would be increasing pressure) to decrease the elevatus?

Dr Blake's comment: Dancer's pads and Reverse Morton's Extensions are one and the same. I would rather give credit to the French who in the 1770s while studying their ballet dancers came up with this unique pad for big toe joint pain. It was the time of the French Revolution, but also the time of this unique pad that was not placed over the sore area, but designed to transfer weight. A truly revolutionary idea!! A dancer's pad should transfer weight from the first metatarsal to the second through 5th metatarsals at push off. When this works, normal push off occurs with the first metatarsal being free to plantarflex for an active push off. When there is too much weight on the first metatarsal (say from over pronation of the foot), then functional jamming and pain can occur as the first metatarsal tries to plantarflex at push off but is being restricted. So, at push off you want normal plantarflexion of the first metatarsal, with normal to slightly less than normal plantar pressures. This can help a pain syndrome produced by that jamming force. And, push off is only one third of stance. Dancer's pads do eliminate a lot of pressure on the first metatarsal during the contact and midstance phases. So, all 3 phases of stance have less pressure on the first metatarsal with a dancer's pad, and active push off should be less restricted and therefore more powerful. Now, a structural met primus elevatus is best helped by a Morton's Extension. It brings the ground up to the first metatarsal and allows it to function normally. A functional met primus elevatus, caused by over pronation, is only elevated by the pronation jamming it upward. It needs arch support to decelerate pronation, shifting the weight in midstance to the middle of the foot, with a dancer's pad to free up the jammed big toe joint. Besides Dr Root, Dr Langer first discussed this concept in the 1980s. Drs Wernick, Langer and Dannenberg introduced the kinetic wedge with first ray cut outs to free up the first metatarsal to achieve wonderful push off. The basic concept was that some arch support, and some first ray freedom, would help the first ray push off. This is achieved in various orthotic modifications. I love adequate over pronation correction from the orthotic device, along with some dancer's pad to give extra freedom. Dancer's pads have been crucial in pain syndromes, and less necessary when there is no pain (although always an option to add). 

Also, If someone has a hallux limitus and a plantar plate tear of the second, would you recommend doing a spica taping to the first and the second toe simultaneously? Your instructional video on Youtube for this is excellent. My mom actually has this issue and I have been trying to research different taping methods since she does not want surgery. I bought her a morton's extension innersole but she also doesn't wear sneakers very often as she is a dancer. She is hypermobile so perhaps using a reverse mortons extension may help the joint align. However, I am worried to add pressure to the sesamoids because she also states she has pain there (hence my confusion on padding). I have included a photo of her foot and x-ray just in case my rambling doesn't make sense.

Dr Blake's comment: Even though you are only a student, you are asking great critical questions. The main treatment for a plantar plate tear is a Budin splint or spica tape to the 2nd/3rd toes (typically buddy tape to share the pressure). Look at the Hapad products. Start with an Extra-Small Longitudinal Medial Arch for the Hallux Limitus to shift weight more central. Add a Budin splint for the 2nd/3rd toes (Single loop opened up for both toes). You can trim the Budin splint plantar padding as much as you like, and you can even add an extra small metatarsal pad to the splint. 

Dr Blake's comment: The xrays point to that long first metatarsal that gets jammed at push off. This is typically initially a functional jamming (functional hallux limitus), which can become osteoarthritis (structural limitus or rigidus). Since you can not load the second met head, you have to support the arch to transfer weight from first to central. 

 She also has a strange lump on the medial 2nd digit. She was told by a podiatrist that it was just bursitis but I am not convinced since it is a hard lump- feels almost like an extension of the medial condyle of the prox phalynx...the x-ray just looks like a bit of increased density in the soft tissue. Have you ever seen something like that before?

Dr Blake's comment: With plantar plate tears, the second toe can start to deviate to the the loss of plantar ligament stability. Here you see the second toe proximal phalanx deviating towards the first toe. She may need that fixed surgically some day. And, today definitely needs to live with a Single loop Budin splint with the loop opened up enough to cover both the second and third toes. I sure hope this helps her and good luck with your career. Rich

I am going to have her start doing the joint mobilization that you recommend in your other blog post.

So sorry for the long e-mail. I really appreciate you taking the time to read this. I am looking forward to your response. 

Best Regards,

Hallux Limitus/Rigidus Playlist

Wednesday's Article of the Week: Possible Future of Synthetic Cartilage Injections in the Big Toe Joint for Hallux Limitus/Rigidus

The article below discusses the complex world of research around Synthetic Cartilage injections for Hallux Limitus/Rigidus. Every Podiatrist is waiting anxiously for approval of a synthetic substance to act like a new cartilage pillow within the big toe joint when injured. In this proposed study, intra-articular Hyaluronan (Synvisc) would be injected into every other patient and sterile saline (salt water) into the other 50%. Everything else would be equal. It would be the only treatment for a 6 month period. Patients would be evaluated many ways:

• pain levels
• function levels
• pain with walking and at rest
• amount of stiffness in the big toe joint
• amount of measured big toe joint dorsiflexion
• plantarflexion strength across the big toe joint
• global satisfaction to treatment
• overall health related quality of life
• magnitude of symptom changes throughout the day
• use of pain relieving medications
• changes in measured pressures in walking of the ball of the foot

Data will be collected at baseline, 1, 3 and 6 months

Up to 3 shots will be given each patient based on symptom relief

Data will be analyzed using the Intent to Treat Principle and other common forms of objective testing.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636797/?report=classic

Dancer's Pads used to off weight Hallux Limitus/Rigidus when it is sore to put weight on the big toe joint.

Hallux Limitus: Podiatrist vs Orthopedist

I was told I have hallux limitus over a year ago.  My podiatrist gave me a shot in my toe and that seem to help for awhile.  He said that I would need to have the joint replaced that after looking at my xray I am bone on bone.  Joint is shot.....not his words.  Anyway, I want to get a second opionion.  I have made an appointment with a good orthopedic for January.  Is this good to go see an ortho too.

Regards,

Dr Blake's response:

     Both professions in general do a good job treating this ailment, but I suspect if you see 4 doctors (podiatrists or orthopedists) you will have 4 different approaches. This is definitely an injury that has its own artistic flare in treatment, and each doc is going to have a different approach. You want to find someone that is an artist as well as a technician. Since no one will make this joint normal again, and treatment typically is life long, find someone that does not necessarily have the "To Cut is To Cure" mentality. In this case, "To Cut is to Start Over" is more like it. You want someone who understands that the surgery should make the joint better for awhile, and that there will be management questions and concerns that come along constantly. I hope this makes sense. I have placed some of my other post links below on this topic. Dr Rich Blake

  http://www.drblakeshealingsole.com/2010/08/hallux-rigidus-surgery-or-no-surgery.html

  http://www.drblakeshealingsole.com/2013/10/hallux-limitusrigidus-examination-with.html

Hallux Limitus/Rigidus Examination with Self Mobilization Technique

This video below discusses the measurement required to make the diagnosis of Hallux Limitus vs Hallux Rigidus along with the self mobilization techniques to improve your range of motion. Please enjoy!!

Hallux Limitus: Email Advice

Hi Dr. Blake,

I discovered your web site a few weeks ago and have found it very informative and helpful.

I have had hallux limitus in my left toe for about 6 years and have tried many things to manage it.  These include NSAIDS, steroid injections,

orthotics (OTC such as Superfeet and Sorbothane as well as custom orthotics), carbon plates, stiff shoes.  In the past year or so, I've noted that

stiff-soled shoes don't seem to help as much.  My podiatrist suggested shoes such as Sketchers Shape Ups or MBT--I've tried these but they

seem to rock in the wrong place (still get painful movement in my toe).  On top of this, I'm having pain at the base of my other toes on both feet

(possibly Morton's neuromas?).

I have tried some of the suggestions on your web site with varying degrees of success.  Icing the joint sometimes helps, but at times increases the pain. 

The joint mobilization does help for short periods.  I have tried the spica taping too, but don't think I'm doing it correctly or else I can't limit the motion of the

toe enough.  I bought Yogatoes and find them beneficial.  I use either iboprofen or naproxen for pain when needed.

I would appreciate your input on next steps in managing my condition.  I've been told my surgical option is fusion, and I'm trying to put that off as long as possible

(I'm 53).  I have wondered if things like the dancers' pad you mention may be helpful or if there are other orthotic/shoe options I could discuss with my

podiatrist and perdorthist (I'm in Atlanta, GA area).  With shoes, I'm wondering if I should try a max motion control shoe like the Brooks Beast.  I'm neutral to slightly

overpronating with a moderate arch, but do have a prominent callous on the inside edge of my left toe.  I ask because early in my treatment, I had a perdorthist who put me

in the Brooks Addiction--this helped, but I realized over time I was walking on the outside edges of my feet and thought it may be doing more harm than good.

Thanks so much for your time.

Dr Blake's comment: 

     I agree with your fighting spirit, since undergoing a unreversable fusion seems too much. Glad you have found some things to help. Perhaps we can arrange that  you send your MRI, so I can see that if surgery is needed, perhaps cheilectomy or joint implant should be considered. These are not permanent, and can get you many years of a more comfortable joint if you are a candidate. Let me know what the dorsiflexion range of motion you have in this joint compared to the other foot. Since the same person measures it, the difference is almost as important as the overal amount. It is important to continue to perfect each technique. Try 3M Nexcare Waterproof tape for more support while spica taping. Definitely start using dancer's pads (get a roll of 1/8th inch adhesive felt from Moore Medical) in all your shoes. If you have stable orthotics, they can be added to the orthotic devices. Definitely ice for 10 minutes 3 times a day the top of the joint. Definitely go to the Brooks Beast for stability. In a month, let me know if this is helping. You can simply add a comment to this post. I hope it helps. Rich

Hallux Rigidus: Email Advice

Hi Dr. Blake




I'm an active 52 year old female with end stage hallux rigidus. My condition was caused 27 years ago when my big toe was jammed into the joint playing soccer.



Each year I would assign a percentage to inconvenience the pain disrupted my daily life. Once the bump appeared about 2 years ago the percentage went up to 90%.



In the past 6 months I've had 3 opinions. Podiatrist wants to clean the joint then a joint replacement in 10 years, orthopedic 1 wants a fusion, orthopedic 2 (top doc in major east coast city) said joint destroyed and severely arthritic. Fusion is my only option.



Your blog is incredible and helped me ask great questions. No one offered spica taping which I just tried a few days ago with great pain relief.



I haven't seen much on what the risks would be if no action is taken. I understand the disease is progressive. Can the joint break.
Dr Blake's comment: No the joint can not break. It is gradually self fusing, but that produces both bone and soft tissue inflammation. The soft tissue inflammation can be controlled with icing 2-3 times per day, occasional cortisone shot or oral cortisone burst, contrast baths 3-4 times per week, spica taping to limit the bend of the joint, NSAIDs occasionally, bouts of PT or acupuncture, and activity modification. 
The bone inflammation is also helped by contrasts baths, possible off label use of a bone stimulator, physical therapy, off weighting the joint with orthotics and dancer pads, and occasionally use of removable boot, stiff hiking boots, carbon graphite plates. Hang in there and see if the above can help you get this calmed down. You were good to get the opinions, of course, if you have any surgery, you would have to get an MRI and possibly CT Scan to analyze the present situation better. Rich



I'm very hesitant to fuse. Although I was told its self fusing. Is it ok to let the body self fuse. I can tolerate the daily pain for the most part.



Thank you for dedicating your time to helping those of us living with this crazy condition.

Hallux Limitus: Successful Conservative Treatment Email

Dr. Blake,

I am only commenting on your blog because i want to simply say thank you. Why? Well, you seem to be one of the very few physicians willing to comment on hallux limitus and rigidus without a pre established agenda. No offense, but I went to see an orthopedic and two podiatrists each of which were selling me a surgery and had me under Anesthesia before the xrays lights went off. Neither suggested any of your conservative approaches before surgery was offered. I found that terribly odd. My pain was bad but i felt there should have been something else said/suggested. After reading your blog and your YouTube videos i learned more about limitus (which i realize i have) and ways to calm the joint down etc. As you said, "it should be treated as a sore joint. Nothing More."

http://www.drblakeshealingsole.com/2010/08/hallux-rigidus-surgery-or-no-surgery.html

I have full Motion in the joint with the small "bump" on the big toe but inflammation after running and power walking etc, Stiffness in early mornings etc. But Spica taping helps as well as whatever else i learn from your info. I think my initial battle was accepting that my body was actually getting older and that's the hardest thing for me. Truly. I'm 39. If/when my condition gets to an unmanageable/intolerable point I'll fly to SF from Chicago and give you a visit without hesitation. Meantime I'll continue following your blog and implementing the advice. Again, thanks.

Dr Blake's comment: 

     I am so happy to hear wonderful responses. Thank you very much. There are too many protocols and cook books, and by gradually applying the sports medicine principles of creating a pain free environment, protection (like with the spica taping), anti-inflammatory like 3 time daily icing, off weighting the sore area, etc, so many problems can be minimized. When there is pain, and our ability to participate in the activities we love, it is sometimes very hard to make a good decision and avoid surgery. You were so smart to get 3 opinions, and very unlucky that they didn't give you options for conservative treatment. I am so happy and proud my blog helped. I wish you the best. Rich

Hallux Rigidus: Email Advice

Dr. Blake, I was recently diagnosed by an orthopedist with Hallux Rigidus. He took X-rays, pronounced I had it, gave me Mobic, said I could never wear flip flops, high heels or even the flats I had on and waved goodbye. (Mobic made me feel dizzy and nauseated, so that was out). Dr Blake's comment: Mobic, generic is meloxicam, is one of the non steriodal anti-inflammatories. There are 9 classes of these drugs, and several may be ideal for you. If this is an option, you need your internist to begin to experiment and find one that really helps. I like the 10 day on and 4 day off rotation. This allows you to detoxify from the drug and the 4 days off should be ample time to decide if the drug is helping you. If not, or unsure, switch to another class of drug for another 10/4 rotation.  http://www.spine-health.com/treatment/pain-medication/types-nsaids http://www.drugs.com/mobic.html Thankfully, I found your website. I was going to buy a Budin Splint, but they don't make them to go over the problem joint/toe which is the big toe? I'm confused. Dr Blake's comment: For the big toe joint, spica taping works like a budin splint for the lesser toes.  I am trying to run/walk, but realize I am no longer walking normal. I am walking on the side of my foot and know this is going to be big trouble- soon. Dr Blake's comment: Limping or favoring the injured area is potentially very damaging and can cause worse problems in your knees and hips. Probably okay when you stand to roll to the outside, but not when you walk and run. You need an insert/dancer's padding that enables you to off weight the sore area without limping.  My toe joint feels like it is on fire at the end of the day. Putting weight on it isn't the problem, but if that joint bends, it honestly feels like it is going to break and hurts like the devil. I just began icing it recently. I have been very careful to buy shoes that exert little to no pressure on this toe joint for years.  Dr Blake's comment: For the next month, ice pack the bottom of the joint for 15 minutes twice daily and do one end of the day contrasts to flush the joint of fluid. This typically works better than medications, although once you are doing your topical treatments, the meds may be a good choice to add.  Exercise has proved daunting and the resulting weight gain has done nothing to ease the pain, as you can imagine. Dr Blake's comment: Stationary Biking has been a great exercise, since you can put the pedal in your arch. Swimming is also great without pushing off the wall with your bad foot. If you can design a good dancer's pad, even elliptical can be used as long as the weight is on the lesser metatarsals and you do not use your arms. It is so crucial you keep your quads/core strong to help support your frame off the foot. Weaker core, more collapse of the foot and more pressure on the big toe joint. Even Pilates and Yoga mat exercises at home with a DVD can prove very important.  I have Voltaren gel, but just used it a couple of times and noticed no difference. Dr Blake's comment: Voltaren gel, or Flector patches can be used on the top of the joint 24/7 since it does not interfere with the Spica taping. You must use for 1 month 3 times a day before you really see the benefit, or decide to not use.  I take aspirin regularly, but dont take Ibuprofen because it raises my blood pressure a lot. I have Aleve, but don't use it much cause I'm afraid of its effects on BP. Dr Blake's comment: I really do not like any of them, unless it is just to help control flares. I would rather you ice and contrast bath. You can ice 10 minutes hourly (when you are home) for a 2 week period to see how that works. It is 100% anti-inflammatory without GI or cardio-vascular side-effects.  Would you advise that I see a podiatrist to get orthotics? I don't intend to have surgery in the near future, so I'll do just about anything else. Dr Blake's comments: Yes, orthotics that take the pressure off the joint with a dancer's pad will be great for some shoes. Other shoes the orthotics will probably place too much pressure on the big toe by crowding the shoe or shifting your weight forward. It is wonderful to have a good pair of orthotics that support the arch and shift the weight to the center of the foot. Consider going up one half shoe size with orthotics. Look into getting carbon plates for some shoes. Also, look into rocker shoes like the New Balance 928 or Mizuno Wave Nirvana. Thank you so much for your blog. I wish I had found this years ago before all the damage had been done. I'm about ready to get the old boot and immobilize my foot. My husband thinks I should get a cortizone shot, but I am hesitant to get hooked on those. Dr Blake's comment: I agree with delaying. You are going to mask pain for awhile with the cortisone, and that could speed up the damage. Begin cortisone only when you have resigned yourself to a joint fusion if it doesn't work. Sure hope this information helps you. Dr Rich Blake I appreciate any help you can give. Thank you again! Jennie (name changed) from Alabama

Sesamoiditis and Hallux Limitus: Email Advice

Hi Doctor,

I've been following your blog closely and I greatly appreciate your helpful optimism and passion to tackle people's ailing foot problems.  I was hoping that you could enlighten me with your opinion on the "Cluffy Wedge". I've pasted a link here http://www.cluffyinstitute.com/. I am struggling with sesamoiditis and hallux limitus, and so far I have found some relief with custom made orthotics from my podiatrist and a handmade, felt version of a dancer's pad which I wear with sturdy soled Dansko shoes. I tried the spica taping from your video with the kinesio tape, but I am unable to have it hold my feet in a sturdy and still position. It seems like despite bringing my toe down and taping it securely, it starts to come lose when I walk because of the necessary flexing motion of my feet that occurs. I stumbled on these cluffy wedges at the Good Feet store here in San Francisco and I thought I might as well try them. However I tried doing some research, and aside from their own site, I can't find many critical evaluations of the product. Are you familiar with them? And in your opinion, could it help with my sesamoiditis and hallux limitus? 

Thanks so much,

Sharon (name changed)

Dear Sharon:

     Thanks for sharing about the Cluffy wedge. Dr Jim Clough was one of my students, and I remember him well. How fun!! There are 3 or 4 very positive effects of his wedge that I put occasionally on my orthotics, but one big negative. The negative, based on how you use your big toe, the Cluffy Wedge may put too much back pressure on the sesamoids and increase the motion across the big toe joint when it should be lessened. These are normal aspects of working on the delicate biomechanics of the orthotic and shoe interface. I have routinely needed to have 3 different orthotic and padding combinations for the 3 main shoes a patient uses. Some made need the cluffy and dancer's, some Morton's extension, some greater arch support, etc. Now that you have written, since I have never actually called the padding I use a Cluffy Wedge, I will begin giving credit where credit is due. Also, try 3M Nexcare Waterproof tape, usually sold at Walgreens, for better stability when taping than Kinesiotape. Hope this helps. Rich

Hallux Limitus/Rigidus: Getting a Good Plan Together to drive the Pain Down

Dear Dr. Blake,

It was so nice seeing you again today!

Thank you very much for the time and direction that you gave my husband and I in your office.

Below, please find the outline that you requested. 

***One quick question:  the dancer’s pad on my left shoe insert has two layers and the one on my right insert only has one layer.  Was this intentional or should I add another layer?***

Please let me know if you’ve thought of anything else that I should be doing.

I will communicate with you on or about February 14 with a progress report.

Many thanks again!

Phase 1:

·         Begin icing 3 times / day for 5 – 10 minutes each time.

·         Take Prednisone as directed for 8 days.

·         Ask Pharmacist if drug interaction with Prednisone and Ambien.

·         Use “dancer’s” pad (moremedical.com)

·         Tape foot as discussed (Kenesio)

·         Begin Egoscue menu(s).

·         Investigate additional shoes =  New balance 928 / Muzano Wave Creation

·         Investigate carbon like insoles.

Phase 2: (after Prednisone program finished)

·         Begin taking Advil – 2 pills 4 times / day Monday thru Friday; no pills on Saturday and Sunday

·         Continue icing 3 times / day for 5 – 10 minutes each time.

·         Continue Egoscue

·         Continue taping

·         Continue dancer’s pad

·         Start walking (as a test)

·         Feb 14^th – check in with Dr. Blake

Phase 3: -- to be determined

·         Series of steroid shots?

·         Iontophoresis patch 80 (Patterson Medical)

Dr Blake's comments: program looks great!! Okay to have slight unevenness between the sides, but make sure it feels okay to you. If not, even the pads totally, or slightly. 

Hi Dr. Blake,

I sure hope that your back is feeling better now!

As we talked about in your office  when I saw you on January 30^th:

I am to follow up with you right about now on the results of taking the Prednisone  and then switching to the Advil. 

(Phase 1 as shown below in the e-mail to you following our visit)

Predisone

Day 1     pain level 9

Day 2     pain level 8         a little better!

Day 3     pain level 7         better – especially in the pm

Day 4     pain level 3         walking well and used glute muscles that have not been used in a bit – gait more even- butt sore from using muscles!

Day 5     pain level 3         felt like I could walk on the treadmill = did not want to push it so did not

Day 6     pain level 4         a little worse

Day 7     pain level 5         inching away from a comfort level = worse

Day 8     pain level 7         continuing to get worse

Advil  (2 Advil 4 X day)

Day 1     pain level 7/8    

Day 2     pain level 7/8

Day 3     pain level 7/8

Day 4     pain level 7/8

Day 5     pain level 7/8

Icing (the entire time)

2 -3 X day for 5 – 8 minutes

Voltaren = patch & gel (started using after I stopped the Prednisone)

Taping = I feel I am not applying the tape correctly = it tends to aggravate the situation.  (I believe that I need to review how far down to pull my toe)

Dancer’s pads = feels great

Shoes = in order to control the pain & be mobile - I must wear Nike sports shoes at all times

I would like to figure out how to utilize some of the “props” that are available so that I can wear other (flat) shoes

Exercise = able to ride the exercise bike and the elliptical machine

Carbon insoles = still trying to find some that are reasonably priced (the ones in your sports shop are $99 each)

Rheumatologist = (upon your suggestion = possible other oral anti-inflammatory avenues)

I have an appointment with the Rheumatologist on February 22^nd. 

My observations:

Felt so good on the days when my pain level decreased while on the Prednisone

Now feeling “lousy” and down about the situation = hate to say it but a little crippled…not happy!

I feel I need to really utilize all “props” available to try and avoid surgery (with your help and other ideas from you)

Questions:

1.  Your comments on my response during the mid cycle of the Prednisone blast that allowed for a few “good” days and pain that was tolerable.   

      Was that a good response and the type that you were looking for?

2.  Do you feel that I  would benefit from  iontophoresis patch 80 ( a possibility that  we discussed in  your office)

3.  Would I benefit from Acupuncture?

4.  The current pain level is too bad to have to live with on a daily basis  ( I could tolerate the level 3 when I was on the Prednisone)

5.   I have a high tolerance for pain but not the direction it is going in right now

6.  Other ideas?

After reviewing:  Please let me know your comments and next step

Do I need to make an appointment with you for follow up?

As you can tell, I continue to need help with this situation.

Thanks so much

Dr Blake's comment:

 Hey, Hope you and your valentine are doing well.

      Glad the Prednisone did knock the pain down at least temporarily, but once you got to more normal doses--10 to 20 mg the inflammation came right back. Unsure why all of the great anti-inflammatory you are doing is not causing some dent in the pain levels. Typically, before we get the pain consistently to levels 2-3 we start seeing fluctuations in the pain level--one day 8 then next 6 then 8 then 4 then 5 then 8 etc. So, how do we accomplish that. 

     The carbon plates may immobilize it better. The Rheumatologist may have better anti-inflammatories to try. One or two shots of short acting cortisone into the joint may help. The ionto patch 80 may work. Acupuncture is a definite yes to try for 6 sessions. We need something to act like the prednisone to tip the scales in our favor. Since you are seeing the rheumatologist, let her try another anti-inflammatory. You can either do 6 accupuncture or 6 ionto patches, I have no strong feeling which would be better since I have had good responses and no responses with either. Rich I love these!!

Hi Dr. Blake,

I LOVE your hearts!  And….Happy Valentine’s to you and your wife too!

Thank you so much for getting back to me.

Interesting enough – the pain level today is down a tick…possibly the flector patch & gel are now starting to kick in.! I am keeping a running schedule of the pain level and activity and will share that with you in a week or two if I see marked improvement one way or the other that would help either way…

·         I will let you know what the rheumatologist has to say regarding another anti-inflammatory after I see her on the 22^nd.

·         Do you know a good acupuncturist that you favor – I would be happy to drive into the city for someone that knows what they are doing and can follow your direction.  Do I need a prescription from you?

·         How do I order and administer the ionto patches?  Do I need a prescription from you?

·         I will purchase the carbon plates and monitor that as well and also try a little less aggressive taping on both toes

·         I think it would be a good idea for me to make another appointment with you in a couple of weeks so that we can talk after trying several of the options above and see which direction is best suited for my situation.  Possibly the injections if all else fails.  Do you agree?

So many thank you’s to you again!

Dr Blake's comment:

  Yes, schedule in 3 weeks. I am sorry, but I have no acupuncturist to recommend. I will try to send you in the next few days an Rx for the Ionto Patches 80. Once you get them, I will have you get the cortisone and make an appt with a PT to show you how it is done. Happy Valentines. Rich

 Thank you Dr. Blake!

I’ll be on the lookout for the Rx for the Ionto Patches 80 and where to order.

In the meantime, I‘ll find a good acupuncturist and start with that and then move to the Ionto patches upon receipt of instructions from you.

I will call your office today for a follow up appointment in 3 weeks.

I am confident that we together will find the correct formula that will help these toes of mine!

Hope your back is behaving…