Hallux Rigidus: Email Advice

Hello Dr. Blake,

I have been reading your very helpful blog for the past month.  It has shed much light on my condition which has become the holy grail of my life....finding how to reduce pain from hallux rigidus. I have the perfect storm of feet:  extremely flat feet, extremely long toes,  and over pronation.  Ran for 17 years 7 without orthotics then got some really hard plastic ones made in the early 90's and stopped running in 2001 but not due to foot pain....which is amazing.  My knees were tallkng to me and so I stopped to preserve them.  Now, I bike, inline skate, and wish to start rowing. I am 58 and have done tons of exercise, cardio, racquetball, hurdles, stepping for the past 33 years.  My weight has always been appropriate for my height. 

This four year saga has had me visiting more than six doctors in the Green Bay/Milwaukee area.  Most let me walk out without any orthotics.  Now I possess two pair and don't know which is best.  

Dr Blake's comment: When you walk with the orthotic devices, see which one transfers your weight through the center of your foot as you push off the ground. It is the same principle when you buy new shoes. See if you can tell when you put on various shoes and walk around the store if you can tell which ones keep you more centered. 

The first pair was created by a pedorthist who works with sports injuries. From a styrofoam mold I stepped into he created a pair with a full Morton's extension for my severely affected left big toe joint.  For the right foot he put in a "barely there" Morton's bump.  I weaned into these across two weeks.  Was able to finally walk without limping (which I had been doing for more than 2 months).  But my joint was still really sore.  So I found a local doc who gave me an injection (not cortisone but instead something that stays in the joint).  This helped substantially but there is still soreness.This doc also made me  orthotics to wear in shoes...so they stop at the fatty pad under the ball of my foot.  He also made a small cut out so my left big toe joint could "move: a bit.  He felt the Morton's extension orthotic would make my toe joint fuse.  Is this true?

Dr Blake's comment: If you have Hallux Rigidus, your joint is fusing. Your job is to make this process less painful, and thus, less disabling. It sounds like you are creating a variety of protected weight bearing options which these various orthotic devices. When you add a variety of potential shoes, occasional dancer's pads, occasional use of spica taping, carbon graphite plates, removable boots for 1-2 weeks if there is a substantial flareup, you should be able to gradually increase your function. 

My dilemma:  which orthotic should I be wearing?  And my second pressing question is this:  Is it possible to have a bone spur on the side of my big toe joint, where it meets my second toe.  That is where it is most sore not directly on top of the joint.  

Dr Blake's comment: I hope I somewhat answered the orthotic question. I will assume that they all will have a positive roll in various shoes, etc. The spurring on the lateral side of the joint is very common. If that is the most painful area, experiment with toe separators to widen the gap between the big toe and second, or bunion taping (a version of spica) to also produce that separation.

Thank you for your time and consideration.  I truly believe it is possible to find the correct orthoitcs and shoes that will stabilize my toe/foot so my condition doesn't worsen.  My arthritis in my toe joint is very minimal.  

Dr Blake's comment: I see a lot of patients with painful big toe joints, with a diagnosis of hallux rigidus, when they have normal big toe joint motion. This is a different injury than Hallux Rigidus, so have someone measure your joint dorsiflexion so a proper diagnosis can be made. 

Sincerely,

Jo Anna

Hallux Limitus/Rigidus: Top 10 Initial Treatments

    The top 10 initial treatments for Hallux Limitus/Rigidus are:

1. Create a pain free (0-2 pain level) environment with some form of immobilization and/or protected weight bearing.
2. 3 times daily use topical anti-inflammatory measures with icing twice and one session of contrast baths (you don’t have to tell anyone about your rubber ducky in in the bath!!).
3. Learn how to spica tape the big toe joint for times you want to immobilize (see my video at YouTube entitled drblakeshealingsole Spica Taping).
4. Learn how to make dancer’s pads for any shoe or boot to off weight the big toe joint. One eighth inch adhesive felt can be purchased from www.mooremedical.com for this purpose.
5. Learn if arch supports are necessary to transfer weight to the arch and middle of your foot. You can try the Red Sole inserts sold online or at stores like REI.
6. See if you can get xrays and an MRI to look at the health of the joint internally.
7. Purchase a carbon graphite plate that can be used in some shoes under the insert to limit the joint motion for some activities.
8. If you were started in a boot to obtain a pain free environment, purchase an Evenup to keep the spine level and avoid back issues.
9. From the day you begin treatment, begin strengthening your feet, and lower extremities. Avoid pain, but this approach will lessen the deconditioning. This can be mean a lot of core work, some cardio on stationary bikes, and specific foot exercises approved by the health care provider (as long as they do not hurt is the general rule).

10. Use adhesive felt on the top of the foot (typically 2 layers of 1/8th inch or just ¼ inch) from www.mooremedical.com next to the bump at the top of the big toe joint, but not over, in any shoe that it helps take pressure off.

Initial Workup Hallux Limitus for potential surgery

This wonderful young lady (my age) presented to the office to discuss surgery on her big toe joints. She has a bone spur on the top of the joint that is painful to wear shoes (especially non athletic). A surgeon had recommended removing the bone spur in a relatively simple procedure by shaving the top of her joint. Where this may be perfect, I have had too many patients that have problems when the joint itself is damaged. Removing the spurs from the top of the foot removes bump pain, but can increase bending pain. The shaving procedures typically cause scarring of the ligaments on top of the joint permanently limited the range of motion further. It is rare that patients get more range of motion after surgery, typically less, so jamming of the joint with bending can occur easier. 

Here are the x rays that she brought into the first visit. We are now going to get MRIs to look at the internal nature of the joints and see if they are damaged. Can you guess what joint has more damage and what joint has less range of motion because of that fact from looking at these photos? First 3 are the left side, and the second 3 are the right side.

It is the left side that is worse in range of motion and pain, but the x rays really can not say that for sure. There are suggestions that both joint surfaces will have too much damage (osteoarthritis) to qualify for this bone shaving. The decision may be to implant or fuse. I prefer to implant these joints, since there is no going back once it is fused. The patient has over 40 degrees of range of motion now on the left and 55 degrees on the right. 

Hallux Limitus/Rigidus: Email Advice

I have hallux limitus/rigidus but would really like to keep running/walking.  Is there a shoe or insert you would recommend to allow me to continue.  I am able to practice yoga but with some pain.  I have constant pain even at rest but don't want to do anything invasive at this point.  I can tell I'm getting more and more depressed without the natural stress release of running or vigorous walking.  Any suggestions?

Regards,

Dr Blake's comment: 

     First of all, with hallux limitus/rigidus the pain is primarily with bending the big toe joint. You definitely should attempt sports that limit that motion like biking, swimming, and elliptical. Secondly, you should work on the 4 areas that affect the big toe (that is covered throughout my blog): shoes that do not bend, carbon graphite inserts that restrict bend, spica taping that restricts bend, and orthotic devices that off weight. Thirdly, you can treat the arthritis daily with a steady dose of anti-inflammatory like icing, traumeel, zyflamend, voltaren gel or flector patches. And fourth of all, get some form of imaging or some way or checking it's progress:xrays, MRIs, CT scans, range of motion examinations, etc. 

     So, what are simple generic responses to your questions:

1. Consider an MRI that you can get every few years if needed?
2. Try cross training with sports that do not need so much toe bend.
3. Experiment with New Balance 928 or Mizuno Wave Nirvana to limit motion.
4. Experiment with Carbon Graphite plates (like Otto Beck)
5. Learn to spica tape
6. Get orthotics to off weight the big toe joint
7. 3 times a day do something to produce an anti-inflammatory effect.
8. Good luck!!

     

Hallux Limitus/Rigidus: Email Advice

Thank you for your wonderful website, which is a godsend! I hope you can guide me: I have been running with hallux rigidus (limitus) in both big toes for some 20 years, finishing 51 marathons. Over the years I have gotten a lot of orthotics custom-made, but none have brought relief to my left big toe. Recently, I have developed Ledderhose on the facia of both feet. Would you have any suggestions about orthotics which would accommodate my problem feet? I am really looking forward to your reply!

Regards,

PS.
I forgot to mention that I have hallux valgus (left big toe) as well as hallux rigidus (both big toes) and Ledderhose (both feet), and some pain in the other toes of the left foot. Which orthotics would you recommend for running shoes ?

Dr Blake's comment: 
     First of all, congratulations on 51 marathons, quite a feat (47 more than me!!). Also, for those that do not know, Ledderhose is disease where the plantar fascia gets very scarred and thickened. Typically, Ledderhose can be injected with cortisone without fear of rupture due to the severe scarring, but I am sure there are exceptions. 

     When you are designing orthotics for a situation like this there are many factors to look at. Let us look at one at a time. 

1. Hallux Limitus: Need enough of arch support and inversion to get the weight into the middle of the foot at push off. The padding in the metatarsal area should be to off weight the first metatarsal (dancer's padding). Occasionally the reverse needs to happen with padding under the first metatarsal to limit the motion (called "Morton's Extension). Also, how stiff should the forefoot be of the shoe? Should you use the New Balance 928 with a stiff rockerbottom sole? Should the orthotic be full length and stiff, like using a Sole OTC orthotic, and then making the forefoot of the device even stiffer. Should you use a carbon graphite plate under the orthotic to get your stiffness?
2. Ledderhose: This is tricky with arch sensitivity. How much pressure can the arch take from an orthotic? Should cortisone be used to reduce the soreness before the orthotic is made? Do you need the arch support part of the orthotic or can you simply use a varus wedge to shift weight for the hallux limitus/big toe joint pain? 

So, these are all the ways you are experiment and begin to individualize the biomechanics for your unique situation. I hope it helps somewhat. Rich

Here is the patient's response:

Dear Rich,

Thanks for your reply. You hit the nail on the head: my problem is that stiff insoles hurt the Ledderhose (of the right foot), while other insoles don’t offer sufficient support and relief to the left rigid hallux. I’ve even tried a stiff (Langer) insole in my left shoe (with a cut-out under the first metatarsal, which mimics Morton’s extension) and a less stiff one in the right shoe: that worked for a couple of mid-long runs but I suspect wouldn’t be advisable, what with sending different signals to the brain, etc.

I’m now using dancer’s padding with fairly pliable orthotics in my Brooks Adrenaline (a shoe which has stood me in good stead over the years—and which I desert for Nike Air Zoom Elites only for the actual marathon races), but that does not offer as much relief as stiffer insoles do.

So I’ll take your advice and start experimenting, investing in a pair of New Balance 928s and in carbon graphite plates; I’m also going to try a real Morton’s extension.

I won’t give up until I’ve done my 100^th marathon!

Thanks for your very welcome advice. May I keep you posted?

Dr Blake's comment: Defintely!! And good luck, one at a time. Rich

Regards,

Big Toe Joint Injury with Hallux Rigidus: Email Advice

Dear Dr Blake

I am emailing to say thanks so much for your blog - it is the clearest, most thorough and most practical site I've come across in all my web searching and I really appreciate it.

I can only imagine how busy you are already answering all the questions on your blog, but I'm also emailing to ask if you could possibly give me some advice.  I have had pain in the ball of my foot for the last 5 1/2 months. At first it was intermittent pain, which felt like a stone bruise under the ball of my foot, but gradually it became more persistent and more painful. Now it is painful all the time and feels like a hot needle in the joint.  Originally I was walking to and from work each day, but had to reduce the amount of walking I was doing, and then reduce it again, and then stop altogether. Despite this, the pain continued to get worse.

It has taken 5 months of various misdiagnoses and so incorrect treatment before I finally got an MRI and was diagnosed with grade 4 osteoarthritis of the lateral sesamoid-metatarsal, with cartilage loss, bone marrow oedema and some osteophyte formation.  (The exact wording of the MRI report is "There is a bone marrow oedema pattern elicited from the lateral sesamoid.  There is no sesamoid fracture or osteonecrosis.  There is lateral sesamoid metatarsal osteoarthritis, with high-grade partial thickness cartilage loss over both sides of the joint and focal exposed bone laterally.  Marginal osteophytes arise off the lateral sesamoid-metartarsal articulation. There is degeneration of the lateral sesamoidal phalangeal ligament which is hyperintense but is not torn.... There is a moderate reactive joint effusion at the MP joint.  Mild reactive bone marrow oedema patter is elicited from the central plantar aspect of the metatarsal head.")
Dr Blake's comment: Okay, you have Hallux Limitus Rigidus/Limitus with degenerative arthritis in the big toe joint. The pain you get is that the joint between the lateral sesamoid and first metatarsal head is inflamed, and everytime you put pressure on the lateral sesamoid it pushes against the sore inflamed first metatarsal head. 

I know you've already answered some questions on sesamoids, all of which I've read, and that has been really helpful.  However, I still am at a loss as to how I should proceed with my own sesamoid problem, and I have received a lot of clearly conflicting (at at times plain wrong) advice so far.
Dr Blake's comment: First of all, you have had this process for years slowly developing, so why does it start hurting now? You can take 2 approaches: remove the lateral sesamoid (not my first choice but probably helpful), or go 3 months in a removable boot with off loading padding and bone stimulator to see if that really calms the joint down. Following the 3 months of boot is a 3 month weaning process off the boot developing protective weight bearing orthotics, shoe selection issues, and foot re-strengthening.

Since my diagnosis I have been frantically googling to try to find out more, but most of what I read is about stress fracture (rather than chronic inflammation).  What I have read online about sesamoiditis is about the tibial sesamoid, with very little written about the lateral sesamoid.

I'm really surprised by the diagnosis because I'm only 45 and I don't fall into any of the usual risk groups - i.e. I've never had an injury to the foot, I never wear high heels, I've got no family history of arthritis, I've never been overweight, I've never had a job where I had to carry heavy loads, and I've never been an athlete and have never been a jogger or done any high impact sports.  I don't have lupus, and I've only got this in one joint, so I understand that means I don't have rheumatoid arthritis.
Dr Blake's comment: Unfortunately, simple mechanical issues like a long first metatarsal and big toe, and/or over pronation can slowly breakdown the joint (along with other issues). The process could have started 30 years ago, and been quite glacial in developing. Do you have a toe first toe? Do you over pronate? How is you bone density and Vit D levels? 

The orthopaedic surgeon I saw said that what I had was extremely difficult to treat, that surgery was not an option he would recommend (or do), and suggested an orthotic cut out.

He referred me on to get a steroid injection, which I'm getting in two days time. He seemed a little non-plussed when I asked him about follow up, and when pushed, suggested I see him again in three month's time.  I've decided I need to rest my foot more to give the cortisone injections the best chance of success so I've arranged for one and half weeks off work after my steroid injections this week, and I've arranged non-teaching duties for the next half a week after that.
Dr Blake's comment: Please avoid the cortisone, unless it is short acting. The long acting can make you feel great for 9 months while you are continuing to do damage. At least think it through as well as you can. I tend to recommend cortisone shots in these situations when surgery is the only other option. I personally think you have many options. 

The orthopaedic surgeon said that there is no exercise I can do that will make it better or worse - I find this hard to believe as although I understand that osteoarthritis is a long term degenerative condition, in my experience there is always some kind of exercise that can have a good or bad effect.  I'm contemplating seeing a sports medicine doctor for a second opinion in the hope that someone like that would be more interested in rehabilitation options.
Dr Blake's comment: Sure, you want to avoid exercises that emphasize bending the toe at push off, but elliptical and cycling, and swimming can normally be done safely (perhaps with a slight modification). 

So, what makes the pain worse are standing, walking and balance exercises.
Dr Blake's comment: You need to develop orthotics that off load enough to allow for standing and flat foot walking. You can balance in the middle of books arranged where their is a hole for the big toe joint to sit in to off weight. You really need to be placed in the Immobilization phase however for right now. If you use an Anklizer boot with float to off weight and then ice pack 20 minutes 3-4 times a day to bring the inflammation down. 

And what I've tried so far in terms of treatment:

Foot exercises (toe spread, metatarsal lift, theraband around toe) - but these made it worse, especially the theraband, so I stopped.
Dr Blake's comment: This is because you are in the Immobilization/Anti-Inflammatory Phase of Rehabilitation. These exercises will be great 4-5 months from now. 

Calf muscle release - didn't seem to make any difference so I stopped.

Anti-inflammatories (causing stomach problems but I'm persevering) and fish oil
Dr Blake's comments: I would save the pills, and go to direct icing, and perhaps once a day contrast bathing with one minute heat/one minute ice repeated for 20 minutes. It may be too early however for any heat. 

Cushioning - originally metatarsal pad (given to me by podiatrist), then a metatarsal pad that I cut a hole in for the sesamoid, but now after online research, I've fashioned a type of dancer's pad made of 1/4 inch foam.
Dr Blake's comment: Great, I love my dancer's pads!!!!

Arch support - through taping and through a store bought with arch support.  Have since been told (by orthopaedic surgeon) not to bother with arch support.
Dr Blake's comment: I love the red Sole insert which is in stores all over (like REI). You can adjust them endlessly since there is no plastic. Sometimes, a shoe repair store, which their handy dandy grinders can help if you need to remove an edge. The role of the arch support is two fold--shift weight into the arch and shift movement towards the center of your foot if you pronate as you roll through your foot into push off. 

Toe taping - I'm also now taping my big toe to restrict upward movement.
Dr Blake's comment: Yes, I love Spica taping!!!

Icing - Generally my foot hasn't looked obviously red or puffy but I've been icing it one to two times a day.  However, I went back to one of the many physios I've seen last week and he noted that the tendon area looked puffy.
Dr Blake's comment: Ice, ice and ice. At least with icing you can multi task. You can ice the bottom of your foot while brushing your teeth, checking emails, eating breakfast lunch and dinner. 5 minutes minimum and 20 minutes maximum. 

Cam boot - At no stage has any of the physios, podiatrist, doctor or orthopaedic surgeon suggested immoblisation of my foot (despite the problem previously being misdiagnosed as a stress fracture).  However, I've decided to give immobilizing it a try, and have rented a cam boot which I've been wearing (with my foam dancer's pad and toe taping) for the last 5 days.
Dr Blake's comment: Yes, minimum of 3 months!!!! 

Up until this point, I've been continuing to go to work, and to my weekly pilates class, but I have cut out all other exercise except that which I can do at home on a mat.
Dr Blake's comment: You need to create a pain free environment. Try to keep the pain level between 0-2, no matter what you are doing. 

I've asked my usual physio to help me put together an exercise programme for the future that replaces the daily walking I used to do with something else, but think for the short term I really need to stop using my foot. This is a problem for me as I have nerve pain down my back that I usually manage through various forms of exercise, the main one being walking (and making sure I don't spend too much time seated). I also have a job where I'm on my feet a lot (teaching).
Dr Blake's comment: Make sure you purchase an EvenUp for the side that does not have the boot. It will help protect your back. 

So my questions are:

I've read that usually you only immobilise a fracture or break, but is it ok for me to use the cam walker? Yes
And if so, for how long? 3-6 months really, but we can talk when you have been 1 month straight in the removable boot and 0-2 pain level has been maintained. 
 Up till my steroid injection? And after my steroid injection? Please delay thoughts of cortisone for now, unless it is only short acting, but I would ice for a month first and wear the boot and see how the inflammation goes down. 
What is usual follow up after steroid injections into a joint - the orthopaedic surgeon said to see him in three months, but shouldn't I have a follow up appointment sooner than that? Isn't it common to need more than one steroid injection?
Do you have any recommended rehab exercises I should do after the injection?
What's the best shoe for someone with my problem? Are rocker type shoes worth the money? Is a stiff soled shoe the best, or a more cushioned type shoe better? Typically you go from removable boot to stiff soled shoe like a Hike and Bike or New Balance 928. While you are in the boot, you are getting a bone stimulator (Exogen) and getting your orthotics perfected with the right arch support and right amount of dancer's padding. 
Why is the lateral sesamoid less commonly a problem than the other sesamoid? Supposedly it bears less weight than the tibial, especially when you pronate or if you have any amount of bunion. Both off weight the lateral or fibular sesamoid and load more the tibial sesamoid. 
 Does this make it harder to treat?  Does this have any implications for treatment? Yes, but not really. Subtle padding issues, surgeons more prone to just remove. I think you have more Hallux Rigidus symptoms right now, and less sesamoid technically. The sesamoid and lateral first metatarsal head cartilage issues means a bone stimulator is crucial. 
Why have I got this and will it continue to get worse? Sounds degenerative which is somewhat luck of the draw. For me it is my back, another the hips, another the ankle, etc. Yes, but learning to live with a problem like this is what sports medicine is all about. Do not feel alone, the world is with you!! And one of my Golden Rules of Foot: Teach the patient, not the imaging results. Another Golden Rule of Foot: Listen to your Body and let it help you create a healing environment. 

(I know you probably can't answer that, but it is really playing on my mind!).  I'm very worried about the long term prognosis for my foot because I'm quite shocked at how quickly it has deteriorated. The pain came on quickly, called a flareup (your first one, which is also the most disconcerting one!!), but the process is very slow in general. You will learn this next year how to minimize the time of flareups, what activities pick on it the most (I purposely gave up golf with my back due to the torque, but have been able to play full court basketball with no problem), develop a relationship with a good orthotic maker, begin a lifetime of foot strengthening exercises, learn to select shoes that you do not pronate into, etc etc. A bunch of learning!!

As I said before, I'm sure you are very busy, but if you can shed any light at all on any of the above, I would really, really appreciate it.

Kind regards

Cindy (name changed)

Dr Blake's comment: I hope my above comments start you towards healing, but you sound like you are already figuring it out. Rich

Here is the patient's response to this post:

Dear Doctor Blake

Thanks very much for taking the time to answer my email.  I'm going to do some reading up about Hallux Rigidus, as suggested.  And don't apologise for disagreeing with previous advice about the steroid injections - I know everyone has a different take and in the end I will have to make my own decision.  My GP has, like you, said that I’ve probably had arthritis for a long time, but only noticed it because it got inflamed and didn’t settle down. She seems to think if I can calm the inflammation down, it should improve, so she's supported the idea of the injections, but honestly, I not sure what I'm going to do.

Dr Blake's comment: You can also consider an 8 day Prednisone (oral cortisone) Burst or 5 PT visits using topical cortisone with Iontophoresis. 

  I think she's probably influenced (as I'm sure I am) by the fact that I need to keep active to manage the other ongoing muscular skeletal problems I have. I am tempted to do the injections and do the immobilisation and all the icing, contrast baths, supplements etc that I can, basically blitz it with everything I can.  Anyway, I've ordered an 'evenup' and am going to keep going with my gut (and your advice!!!) in the meantime and keep on immobilising my foot.  I'm interested in the EXOGON device you recommend - I read about this in a post on your blog from another person in Australia (that's where I live), and he mentioned renting one.  I'm going to investigate it further.   How long do people use these for - is it for long term maintenance of joint cartilage or just for acute stages? 

Dr Blake's comment: It is for the next 9 months to see if the cartilage under the first metatarsal head and the injured sesamoid can strengthen themselves.

In regard to your questions: . Do you have a long first toe? .Do you over pronate? How is you bone density and Vit D levels? No other problems with any other toes.  No real biomechanical problems (according to a couple of podiatrists in the past about other issues), bone density fine (got it checked after I was initially told my foot problems was a stress fracture) and I'm guessing my Vit D levels are fine as I live in a sunny place!

When you said: Sure, you want to avoid exercises that emphasize bending the toe at push off, but elliptical and cycling, and swimming can normally be done safely (perhaps with a slight modification). does that mean after 1-3 months in a boot, or during the same period?  One physio has suggested to me deep water walking as a possible exercise.  Does that sound like too much foot bending to you?  (She's suggested it because I can't do much bike riding because of knee problem - bout 10 minutes is tops, and can't swim because of shoulder problem - yep, I'm a complicated case ) 

Dr Blake's comment: There are 3 phases of Injury Rehabilitation--Immobilization, Re-Strengthening, and Return to Activity. You definitely need to be in the Immobilization Phase. The Removable Boot and Anti-Inflammatory measures should really calm your foot down. However, some foot strengthening and some cardio/core workouts are not only fine but crucial to a faster rehabilitation. You have to see the post entitled Good vs Bad Pain and memorize it. Keep the pain level between 0-2. Swim in the deep end of the pool if you can control the pain level, cycle 100 miles if the shoe or pedal position can be modified to avoid irritating the area consistently. 

 And finally, in response to your comment: You will learn this next year how to minimize the time of flareups, what activities pick on it the most (I purposely gave up golf with my back due to the torque, but have been able to play full court basketball with no problem), develop a relationship with a good orthotic maker, begin a lifetime of foot strengthening exercises, learn to select shoes that you do not pronate into, etc etc. A bunch of learning!!  Yes, I know what you mean, it is a life long project.  Unfotunately at times it feels like learning to adapt and compromise is neverending as I already have learned to manage chronic pain from ongoing back and shoulder problems.

Thanks very much for your advice and words of support in your reply on your blog.

Kind regards

Hallux Rigidus: Email Advice

Hi, I was diagnosed with hallux rigidus a year ago.

 I'm a 40 year old male that was fairly active doing things like running, triathlon, ultimate frisbee.  I've see 3 different doctors about my toe, all recommended surgery saying it was advanced, but I'm still on the fence. 

 At this point, I'm able to run 3 miles once a week with minimal pain the day after.  I'm using a morton's extensions and very stiff running shoes.  Besides the weekly run, I ride my bike.  I would really like to get back into ultimate frisbee but I'm pretty sure it's what caused the problem as it's much harder on my foot than running.  

 I'd like to come up with a plan on how to get back to playing ultimate frisbee, even it it means having surgery.   Should i just start playing and hope my joint self-fuses?  Or perhaps the hard answer is that my ultimate frisbee days are gone, if I want to still want to walk normally when I'm 70.  

 Any advice you could provide would be appreciated.  I live in the south bay and would be willing to drive up to see you, do you accept blue shield ppo?  Finally, I do have a soft copy of my xrays if you care to take a look.   Thank you

Regards,
Carl (name changed)

Dr Blake's response, 

     Thanx for the email Carl. Your ultimate frisbee days are over for now (hopefully temporarily), since it is just too hard to control the forces with all the cuts and uneven terrain. Typically, we get you comfortable at cycling first, then running, and then begin to introduce side to side stresses. The pain you have to avoid is the pain that comes on during a workout, that you ignore. And, any pain that begins to effect your gait can mess something else worse. Xrays are less important than MRIs and CT scans so I would progress your diagnostics to include these. Let us get a good 3D image of your big toe joint in 2014, and will be able to use these as baselines. Like any arthritic conditiion, you need to be icing for 10-15 minutes 3 times per day, no matter the workout, but especially as soon as you work out. This alone should enable you to do more. You need to learn spica taping and be great at it. This is for all your workouts. Most patients with Hallux Rigidus (less than 30 degrees of big toe joint dorsiflexion) feel better with dancer's pads, not Morton's Extensions so work on that. You will definitely need an orthotic to shift weight to the center of your foot and off the big toe joint. There are many times that athletes need a little different correction for cycling vs running vs ultimate frisbee so multiple pairs may be in order. Have someone measure the big toe joint, I have a video on that, to see exactly how much motion you have. It is hard, but typically doable to gain 20 degrees with anti-inflammatory, physical therapy, and self mobilization. So, if you are really 50 degrees (Hallux Limitus) not 30 degrees or less (Hallux Rigidus), that may help you. I hope this helps you some. Rich

Tuesday's Question of the Week: Hallux Rigidus

Hi, Dr. Blake, 

It is almost a year later since I first wrote you, and I wanted to update you.  I went to a podiatrist who said I had to have surgery and gave me a cortizone shot which did absolutely nothing. I then managed to get in to see a podiatrist whom works with our local celebrity Orthopedist in Birmingham, Alabama. He took xrays (nobody has even suggested taking an MRI) and pronounced surgery the only option... total fusion. I wouldn't be able to do anything for 11 weeks....WHAAA??? It's my right foot so (unless I purchase a British car) no driving. I can't remember how much of the 11 weeks I'd be almost completely immobile because the whole conversation sent my mind reeling.

Dr Blake's comment: Typically, you are totally off your foot 10-12 weeks with a fusion of any joint, since it takes time for the fusion to take. You can use Roll ABouts and Crutches, but no weight bearing. Then, you start the 3 months of gradual to full weight weightbearing with some physical therapy. So, 6 months after surgery, you typically are close to where you were before only with no pain in the big toe joint. 

I have tried contrasting baths which has offered lessening of pain somewhat, but not much. I am definitely pronating and the old hips and knees are sure to suffer. I have also gained at least 10 pounds in a year due to lack of movement. I will definitely increase my Vitamin D intake and head out into the sunshine, but wondered what else I can do.

a) Do you know a physician/podiatrist/witch doctor in this area that won't immediately head for the default setting of fusion?

Dr Blake's comment: Try going to the AAPSM website and look for podiatrists in your area. Typically these are podiatrists who are sports minded and less surgically minded. At least a starting point!!

b) Where can I get the best (and hopefully not too $$$$) orthotics? 

Dr Blake's comment: AliedOSI labs in Indianapolis, Indiana. They are a big national orthotic lab. Talk Kathy Dubois and mention my name and your need to locate someone near you. I think this is a good starting point. She is wonderful!!

Kathy Dubois
Territory Consultant   kdubois@aolabs.com

c) Is there otc pain med (gel) that would help? (what in the world is Blumjk..must I go to Norway to get it?) 

Dr Blake's comment: See if you can get Voltaren 1% Gel prescribed which you apply 3 times a day, along with Icing 10 minutes 2 times per day. There are many compounding creams/lotions that may help more, but you have to experiment and they tend to be costly. 

d) Should and where can I order a boot to calm ornery toe joint down?

Dr Blake's comment: Definitely, these boots need to be part of your wardrobe when the joint gets flared up. As soon as it does, go to the boot to calm things down. Wear 3 days longer than you think you need to. My current favorite is from Ovation Medical.

http://www.ovationmed.com/

The idea of a fusion sounds insane and having read a lot from your blog; it sounds like the surgery is just the BEGINNING of more problems.

Dr Blake's comment: I am not as sour on big toe joint fusions as I use to be, but the patient must be very carefully selected and informed on all the choices/possibilities. There is no going back, so that bothers me. It completely, and suddenly, eliminates all big toe joint ROM and that bothers me. It is the sudden loss that I find the body has a hard time dealing with, not the gradual loss as you naturally go from Hallux Limitus to Hallux Rigidus. That being said, we are adaptable creatures. We can do this, but it can be a great challenge. I have never seen a study, although it probably exists, to look at the common body compensations and resultant problems after big toe joint fusion. Fuse if it must be fused, but make sure every i is dotted and t crossed before making that decision. 

The last doc said I have only 10% movement in my toe (and only 60% in my left foot...EEGAD, et tu, Brute?!?!) 

Dr Blake's comment: I just love you and your humor. Good for you, because you have to be able to laugh at the situation, yourself, and anything else that tickles your fancy!! If you have only 10%, or 6-8 degrees, fusing the toe is less traumatic to your body than if you had 30 or 40 degrees. 

The pain is obviously pretty severe because coming from a physician's family, we, of course, never ever seek medical advice unless we are at death's door. 

Dr Blake's comment: Amen!!! 

From the first orthopedic visit over three years ago, where the doc said take Moebic and then return for surgery when I can no longer stand it (NO mention of boot, orthotics, otc gels...said there was nothing I could do.) ,to the podiatrist who loves cortizone and surgery to the Sports Med guy who insists on total fusion; I'd say I wish I had sought help earlier, but it looks like everyone would have opted for a "wait and see...and suffer" approach anyway.

I do not want this surgery, Dr. Blake. If there is anyone in the Alabama or Georgia area (how bout the entire Southeast) you could recommend, I would gladly limp over.

Dr Blake's comment: Please look up Drs Perry Julian and Edward Lopez. Let me know what they say. Good Luck. Rich

http://www.aapsm.org/members.html

Thank you so much for this blog. It's giving people hope and probably years of surgery/pain free feet!

Jane (name changed)

Hallux Limitus/Rigidus: Email Advice

Hi Dr. Blake!  

Thank you for this wonderful blog!  I have been dealing with an injured (and re-injured) left MTP joint for years now.  It recently felt bad enough that I sought out my GP.  X-rays showed mild-moderate 1st MTP joint degenerative disease with joint space narrowing, subchondral sclerosis & cystic changes and osteophyte formation.  I tried googling all this, but would love it if you could explain these in lay person terms. 

Dr Blake's comment: You have arthritis in your big toe joint which is causing pain. Below are some links to Hallux Limitus/Rigidus which are degrees of restricted range of motion that develop as the arthritis worsens. 

http://www.drblakeshealingsole.com/search/label/Hallux%20Limitus%2F%20Rigidus

 I have a little range of motion loss compared to the other side, but I still think it's around 60 degrees.  Am I on the road to hallux limitus? 
Dr Blake's comment: Yes, and you need to daily do the self mobilization technique in my video below. Also, if you pronate, get orthotics for your most strenuous activities. Place dancer's pads in any shoes you can. 

 My main complaints are the pain and swelling that occur after walking around with  shoes with 1" or 1-1/2" heels as well as after tap dancing.  I am currently not tapping, but would love to return to it, but am worried about irritating the joint.  Lastly, I see you mentioning dancer's pads often.  Do you have instructions on how to craft one?  I appreciate any advice and help!

Here a dancer's pad to float the first metatarsal head is made of Spenco material and glued to the bottom of the shoe insole. 1/8th inch to 1/4th is normal, but you should never feel like you are falling into the hole created.

Here the 1/8th inch adhesive felt from www.mooremedical.com is being used to change weight bearing off of the 5th metatarsal. 

Dr Blake's comment: You should do just fine with tap dancing with icing twice daily to reduce the inflammation, dancer's padding with 1/8th inch adhesive felt from www.mooremedical.com, use of Hapad Longitudinal Medial Arch Pads for the shoes from www.hapad.com. You may also need to learn to spica tape. 

Here Small Longitudinal Medial Arch Pads from the Hapad company are used as an arch support to transfer weight from the big toe joint into the arch and also into the 2nd and 3rd metatarsals and off the big toe joint. Because it is an adhesive felt, it can be moved around and thinned by peeling when needed. 

Always,