Tiem Bike Shoes with Embedded Cleats

For times when I want to immobilize the bend of the big toe joint for a while, but do not want the unevenness of a removable boot, I use bike shoes with embedded cleat. A patient came in with one the other day that I am using for a plantar fascial partial tear. I also use for sesamoid fractures, plantar plate tears, and hallux rigidus. 

Plantar View with Embedded Cleat

Top View of Tiem Bike Shoe

Cross Section Heel 
Area showing Partial Tear Plantar Fascia

Review Article For Hallux Rigidus sufferers concerning surgery

https://pubmed.ncbi.nlm.nih.gov/32153308/

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

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

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

Hallux Rigidus: Position Paper on Treatment

     Hallux Rigidus means that there is joint limitation of the first metatarsal phalangeal joint to a degree of 30 degrees dorsiflexion motion or less non-weightbearing or 10-15 degrees or less weightbearing standing or walking. Hallux Rigidus is normally associated with significant arthritic changes in the first metatarsal phalangeal joint. These joint arthritic changes can develop from old trauma or long standing microtrauma at the joint level eventually leading to observable joint changes. These joint changes can be spur formation, joint narrowing, and other signs of cartilage loss. When a patient presents with pain in the big toe joint, in the present of a joint arthritic condition, too often the first treatment is surgical fusion. Surgical fusion of the first metatarsal phalangeal joint is typically permanently successful in eliminating pain in the big toe joint, but opens the door for devastating problems in the foot, ankle, and above (at least into the low back). Patients being worked up for first metatarsal phalangeal joint fusions should be told the potential negative effects on the rest of the body and be given full availability to all of the conservative and surgical treatments to the big toe joint. The surgical procedure of total fusion of the first metatarsal phalangeal joint is on the up rise in utilization in medicine. Follow up on the patients undergoing this procedure needs to look at so much more than just pain reduction at the big toe joint level. These follow up screenings should look at the presence of new pain syndromes developing after the patient begins to walk again over the next 5 years.

     When surgery is contemplated for hallux rigidus, the standard treatments of cheilectomy, joint replacements, metatarsal osteotomies, and Keller procedures should be considered even if the expectation is that these procedures are temporary. Besides routine weight bearing x ray evaluations, MRI scans should be more routine. These MRI scans will pick up more of the 3 dimensional anatomy of the diseased joint and can lean procedure consideration potentially away from joint fusions. 

     When treating a patient with hallux rigidus and documented arthritic changes in the joint, conservative treatment should be done to attempt to bring the overall pain to 0-2 (VAS) routinely. This pain reduction should be both attempted to get the patient feeling more comfortable by whatever means, and then maintained as the patient's exercise program is returned to normal. It is the author's opinion that getting out of pain will allow the patient to make a more informed consent on surgery and what type to do. If the treating physician does not have the ability within their clinical setting to attempt robust conservative treatment, the treating physician should make appropriate referrals. These conservative treatments include custom foot orthotic devices, spica taping, cluffy wedges, rocker bottom shoes, bike shoes with embedded cleats, etc. No long acting "acetate" cortisone should be used to reduce pain in an arthritic joint. Icing, contrast bathing, and physical therapy to reduce joint inflammation can all be helpful at lowering the overall pain levels. It is recommended that physicians refer their patients to the Hallux Rigidus Facebook Page run by Dr Eddie Davis and have their prospective surgical patients talk to patients whom have had the surgery 5 years or more earlier. 

     As we walk, we need to bend through our big toe joint for normal push off. This allows the transfer of weight to go from one foot to another with the least stress on the body. When our bodies are unable to bend the big toe joint after fusion, we begin to compensate in many ways. Of course, you must inform your pre-surgical patients that they made need both foot orthotic devices and rocker style shoes, like the Hoka One One, for the rest of their lives. The common compensations are subtalar joint excessive supination to transfer body weight laterally with all its problems up the kinetic chain. Also, excessive out toeing enables the patient to roll through the medial side of the foot without bending the big toe joint producing abnormal forces on the arch, medial ankle, knee and hip particularly. When the patient begins to hurt their knee for example with these compensations, what orthopedic surgeon is going to take the time to figure out what the foot needs? None of them will at least before they fix the knee with another surgery. 

     The key points of this position paper on Hallux Rigidus Surgery are:

1. Make sure that the patient understands all surgical options
2. Make sure that the patient is given a good opportunity to get the pain down to 0-2 VAS for 3-6 months before a surgical decision is made (a good attempt at conservative treatment)
3. Make sure that the workup includes x rays and MRIs (even when the health plan does not pay for)
4. Make sure that the patient understands that if they develop pain from compensating that they may need to be restricted to certain shoes and orthotic devices for the rest of their lives
5. Make sure that patients are given the ability to talk to patients whose big toe joint fusions were over 5 years ago.  

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

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

Dancer's Padding: How To Video

https://youtu.be/GG-mSjtSwj8

     Dancer's padding was introduced by the French studying ballet injuries in the 1700s. It has a modern term of "Reverse Morton's Extensions". The current supplier for my patients is Amazon, and I can only find the 1/4 inch which you will have to thin out. 

https://www.amazon.com/Felt-Adhesive-Orthopedic-Aetna-Corporation/dp/B071KTF794/ref=sr_1_14?crid=2AO6K692L8XR&keywords=self+adhesive+felt+roll+medical+use+1%2F8&qid=1664597257&qu=eyJxc2MiOiIwLjAwIiwicXNhIjoiMC4wMCIsInFzcCI6IjAuMDAifQ%3D%3D&sprefix=adhesive+felt+roll%2Caps%2C179&sr=8-14

     I use this material constantly in my Podiatry practice, and give supplies to my patients. Any problem with the big toe joint, and some cases of plantar fasciitis, and arch pain, you want to see if this padding helps the symptoms. 

This is demonstrating the Dr Jills Dancer's Padding with Adhesive Gel

Hallux Rigidus: Surgery, No Surgery, or In Between

Here is the right big toe joint of someone whom has some minor DJD

(Degenerative Joint Disease AKA Wear and Tear)

Here is the left big toe joint of the same person with significant DJD

     Hallux Rigidus for many is a painful arthritic big toe joint. Patients can present with pain for many years or recent. Typically, like any sore joint, you can use common sense and get the joint comfortable. You may be just holding off the inevitable, the surgical knife, but who says that this is not worthwhile. 

Surgery is not without its problems. Most surgeries last 10-15 years and then have to be redone. If you fuse the big toe joint, you may not have big toe joint pain again, but you have totally messed up the normal pattern of movement. Our body must compensate for limping in pain, and it must compensate when a major joint is locked up permanently. 

     There are so many thoughts that run through my mind with this patient. One concerns why is the left side more broken down. We could discuss this for hours. Commonly, the left foot in our predominately right handed society gets beat up more. It is our support foot or support side that always takes more load in some way or another. Yet, podiatrists love to look for the nuisances to a pain syndrome like this. What also may put more pressure on the left big toe joint? Asymmetrical pronation is one, where the pronation or arch collapse places incredible stress on the big toe joint. Tight achilles and hamstrings, long leg syndrome, bone structural differences between the two sides, etc, all can place more force on the big toe joint which slowly and gradually collapses under this pressure. 

     Having been in a sports medicine and biomechanics practice my whole life, I have come to appreciate a non-rush attitude into surgery. Get more than one surgical opinion, and do not tell one surgeon what the other said. Find out if anyone can treat your problem conservatively. It is great to find out if there are mechanics that aggravate the stress at the injury that can be reversed. It is also great just to calm down the inflammation and relax any irritable nerves. 

     The last point today: treat the patient, not the xray. 

     

Timing of Hallux Rigidus Surgery: Now or Can We Wait and Get more Information

Dear Dr. Blake,

You can imagine my surprise when a podiatrist here in Davis, California just told me that the bunion bothering me is Hallux Rigidus! 

Apparently my daughter whom you have seen inherited this condition from me. Since you took such super good care of her I really hope you can see me too. The first available appointment with your reception is April 16. I plan to be in NM visiting my grandkids March 18-April 15, and since those visits include tons of hiking I would greatly appreciate it if you can somehow see me before I go.The x-rays today showed NO cartilage left, and the doctor suggested fusion surgery and orthotics. Apparently I should have been using orthotics for years now, but the podiatrist I saw for the bunion in 2015 told me simply to wear shoes with a slight heel lift and I’d be fine. Hmm...I went to today’s appointment because the toe area often hurts and clicks as I walk. I still play tennis 5 days a week and am generally very active, so I dearly hope you can help me!

Thanks,

Dr. Blake's comment: 

Thanks for your email and compliments. For sure I should be able to see you. Call and make sure you are on the wait list. Surgery can always be done, so if you can put it off indefinitely, that would be nice. Right now surgery and your symptoms make no sense. Rich
If you can make it, tell them I can see you 11:30 on 3/5 Friday

Addendum: The patient was able to schedule at that time. Rich 

Dr. Blake's further comments: I am not a surgeon although trained as one. Just not my interest, so I gave it up to be home more when my kids were small, but also to focus on sports medicine and biomechanics my true loves in podiatry. In situations like this, meaning problems that may need surgery at some point, I love to be able to work with a surgeon so the patient understands the whole process. The assessments I routinely use in this scenario are:

• Assess when the health of the patient needs immediate surgery (like in alot of fractures we see in sports medicine)
• Assess if the risks of surgery are less than the patient's problem (said another way----the patients disability now has to be worth the disability short and long term from the surgery)

If we use this rationale, yes, the patient may need surgery, but their activity level now is too high to warrant that surgery. They should know about the surgery, but what if there is a complication and the patient can not play tennis again? 

Some of this reminds me of how doctors get in trouble giving too many pain pills. Some of it is because they do not want the patient to have pain. Some of it is that they do not want to be looked at as a bad doctor. This is why I search for ways daily at getting my patients in the 0-2 pain level out of 10 consistently. If they can not accomplish this, we can talk about surgery and definitely get some opinions. Just because the xrays or MRI indicate a problem, does not mean we have to address that problem with surgery. Rich 

Hallux Rigidus: Email Advice

Hi there Doctor  Rich..... you earned it and I feel I need to address you appropriately),

Today, I just returned from yet one more podiatrist visit.  And now...I am thoroughly confused.  Let me back up a bit....I had been searching for foot help on the internet.  That's how I found your blog.  I also found Dr. Huppen of Seattle, WA.  You both have very extensive sites with great information.  Regarding Dr. Huppen who I found first...well, his site was so amazing and helpful about orthotics and showing foot anatomy and what happens when a flat foot walks without support that I actually called his office for a reference.  He publishes articles and speaks at conferences and I thought in his travels he might know someone in the Milwaukee area.  He did refer me to a Dr. Brant McCarten who was familiar with Dr. Huppen.  And then ....I found your blog which was so helpful. But I can't fly to Seattle or San Francisco, so I went to visit Dr. McCarten hoping that all I needed were the right orthotics and appropriate shoes and my hallux rigidus would stabalize and I could live without a chielectomy.

So my plan right now is this....I am having orthotics made with support under the middle of my foot to alleviate pressure on big toe and support my flat feet.  This orthotic...it will not be under my big toe...Dr M. wants my toe to move somewhat as that is what it is meant to do,so it will end before it hits the base of my toes.   But Dr. M outlined how he could very easily help my problem....do a cheilectomy.  

Why I am writing to you....I would like to hear your thoughts about the chilectomy procedure and it's ability to alleviate hallux rigidus. I have heard that having the cheilectomy is a slippery slope which ultimately leads to the fusion surgery.   I truly don't want to have the surgery that fuses it.  Can't wrap my head around that right now. I have read about folks that were very happy with the results after having the chilectomy.  I have also read about those that were unhappy with the results.  This doc has done many of these procedures....he works with lots of athletes.  

I have been very athletic ...for the past 33 yrs...running (which I stopped 14 yrs ago) biking, inline skating, cardio/stepping....racquetball.  And now my life is whittled down....mostly doing pool work....swimming into a stream (I don't know the exact name of it), and other water aerobics.  A little bit of inside biking and elliptical...but my heels are starting to hurt recently.    I have to walk very slowly in the orthotics that I have so my joint doesn't hurt...so I am even moving slower these days.  It's getting to me emotionally, I regret to say.  I know I have to wait till these orthotics come in and see if they need adjustment...then I have to wean into them.

And as I sit here...I can feel my heels talking to me....not sure if it's cause the Xelero sneakers which are new...and possibly are too dense and don't give enough.  I have been on a never ending search for comfortable work shoes (I am an elementary school teacher...walking on hard stone tiles all day).  

So Doc, I would appreciate your thoughts.  And suggestions for shoes.  I have very narrow feet as well.  

With respect,

Jenna (name changed due to witness protection)

Dear Jenna, 

     Thank you so very much for the wonderful email. Cheilectomy is a wonderful procedure, but can go wrong even in the best surgeon's hands. They need to have a feel on how much bone and good cartilage to remove from the top of the joint (typically as little as possible but still get the job done). Lack of pre-op MRIs are one of the major causes of poor results. The MRI should point to where all of the bone spurs to be removed are, and if removing them will lead to joint restrictions post op. The MRI will also tell the surgeon if there are significant cartilage damage deep within the joint that may warrant a joint replacement in the future, or at least micro fracture surgery at the same time of the cheilectomy. The standing AP foot x-rays should tell the surgeon if the first metatarsal also should be shortened at the time of the surgery with an osteotomy (surgical bone break with screw fixation). So, I am not afraid of cheilectomies. They work best with mainly medial and lateral spurring, and least with major dorsal (top) spurring with absence of dorsal cartilage. The more the dorsal bone needs to be removed, the more post op physical therapy is needed to attempt to get the range of motion back, and probably the more luck is needed. From 2 weeks, when the stitches come out, to 12 weeks, physical therapy is crucial in a lot of instances when the dreaded frozen toe syndrome is expected. Golden Rule of Foot: Go into a cheilectomy with Plan B as a joint replacement, not fusion. I hope this helps. I will have to discuss narrow work shoes at another time. Rich

Hallux Rigidus: Consider New Balance Fresh Foam 980

Dr Blake

 

I hope this note finds you well. 

 

 I wanted to let you know about my experience with the New Balance fresh foam 980. I've been dealing with hallux rigidus for about 20 years now, with reasonable success running with orthotics (I've had a much better experience than many of the people with hallux rigidus I've read about on your blog so I guess I can't complain too much). 

 

I got a new set of orthotics recently and was recommended to try a neutral shoe with them. I've always run in support or motion control shoes with orthotics before, so I had little experience with neutral shoes, but happened to try on a pair of 980s for the heck of it.  New Balance advertised the 980 as their entry into "max cushioning"; however, the 980 cushioning is rather firm, not mushy,  and   providing a stable base for the orthotics. The forefoot is stiff, and the outersole has a mild rocker, so  toe off is smooth. Importantly for me, the 980 comes in 4E widths (unlike Hoka One One), and the forefoot is very deep so it doesn't rub against the bone spurs on my big toe joint. 

 

Cheers

 

Jim 

Dr Blake's comment: Thanks Jim, It sounds good for most forefoot injuries like Hallux Rigidus, Sesamoid Injuries, Morton's Neuroma, etc. I will post it on my blog. From reading the reviews below, it runs narrow, and may not work for patients with high arches. 

http://www.newbalance.com/pd/fresh-foam-980/M980.html#color=Blue_with_Green Gecko_and_Neon Orange

Hallux Rigidus: Email Advice

Dear Dr. Blake,  How very kind of you to give of your time and knowledge on your blog and actually answer all of us poor folk!

I will be brief.  I crushed my foot June, this year.  5 bones have healed, but I am not quite weight bearing yet, due to the trauma to nerves, tissue.  No bones were broken in my big toe but it is stiff even after several weeks of physical therapy.  My surgeon says it is HR and showed me a bone spur on top in x-ray which is, he says, the cause of the lack of motion.  The joint looks OK.  I have read that these spurs can result from trauma which it must have because I had full use of my toe before the accident.  The Dr. wants to remove the spur and some of the bone beneath it to give room for the toe to bend up.  If he sees that the joint is not in fact good when he does the surgery he would then do a joint replacement. 
1.   Is that the only way to remove this spur?  Is this a reasonable solution?

Dr Blake's comment: From trauma to surgery, this is too fast a progression. I would wait one year minimum before entertaining a surgical approach, unless the pain was out of control, and/or you have more information for me other then a bone spur and stiffness. Have the physical therapist continue to work on it pain free. Start doing the joint mob on the video below twice daily. Let me know how painful the joint is, and we can discuss spica taping, orthotics, shoe selection, Flector patches, PT modalities, topical meds, injections, dancer's pads, etc. 

2.  I will ask the Dr. and PT, but would like your opinion.  Am I making the spur worse working at increasing the motion with physical therapy, forcing the toe to bend more?  

Dr Blake's comment: Yes, gradually increase ROM pain free. If there was just scar tissue, PTs are wonderful at pushing through pain to achieve better motion. But spurs imply subtle cartilage damage, and need a more gentle approach. In this scenario, I never recommend pushing through pain (although I am sure that there are skilled practitioners who can do it). 

3.  Is there more a podiatrist can do for me? 

Dr Blake's comment: See my comments above on taping etc. The best you can do is gently get the joint moving, while creating more and more activity painlessly which will stretch out the soft tissue. Gradually advance your activity from walking to running etc. As you attempt more activity, treatment options come up from your podiatrist, PT, etc as you try to do the activity and not produce a pain response over level 2 on the pain scale. You are advancing from the Immobilization Phase of Rehabilitation, through the ReStrengthening Phase, into the Return To Activity Phase, and this all takes good individualized thoughts to help you through. I sure hope this helps you. Rich

Thank you,  Jill (name changed)

Hallux Rigidus: Great Comments from patient after Joint Fusion

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

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

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


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

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

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

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

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

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

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

Hallux Rigidus And Abnormal Skin Discoloration: Email Advice

Hello Dr. Blake,

     I am a 56 year old female.  I have been dealing with hallux rigidus for three years.
Dr Blake's comment: Hallux Rigidus is defined as stiffness in the Big Toe Joint of less than 30 degrees of dorsiflexion (the bend of the joint as we try and push off). Normally the big toe joint (called the first metatarsal phalangeal joint) is between 75-90 degrees of bend. We normally need 75 degrees to comfortably function in sports, and 60 degrees for normal walking. This is a common measurement taken. 

     Tonight my pain level is around 7.
Dr Blake's comment: My favorite post on this blog is called Good Pain vs Bad Pain. Good Pain is considered pain levels of 0-2 on a pain scale of 0-10. 10 means you are in very serious pain and 1 means you are annoyed but still smiling since the San Francisco Giants just beat the Detroit Tigers in the 2012 World Series. 7 is getting very bad and we need to fix ASAP. 



     My left big toe joint is totally frozen.  It swells.  It bruises.  I walk funny.  Since Sunday my knee on that side is sorta clicking/popping when I walk.  My ankle swells.

    My foot looks awful.  It’s like it is continuously bruised around the joint, along the base of the toes and on the top of the foot though I think some might be due to meds that I take and sun exposure and the rest to reinjuring it over and over.  It’s ugly.

Dr Blake's comment: I definitely agree that the discoloration is something different than the normal Hallux Rigidus. It seems to especially involve the first 3 toes and could be some form of arthritic or vascular problem. Is the temperature normal? If it is colder, I would say see a vascular specialist, if warmer, an arthritis specialist. Is the pain all from the big toe joint, or are other joints involved? All Anti-Inflammatory Medication can cause abnormal bleeding. Simple blood tests can tell us if you have any abnormal bleeding problems. 

     I have never worn high heels in my life because I am tall.  For the past five years I have been limited to flats.  Three years ago I fell off of chair and came down on that toe.  I already had damage there but this time it was the worse.  When I went into the E.R. they thought it was a broken bone but found it was arthritis and bone fragments.  They referred me to a podiatrist.  I let it heal and did not go into the podiatrist until I damaged it again last winter.  This time I had pain throughout the foot and was put on steroids for soft tissue damage.
Dr Blake's comments: You are not going to get any absolution of your sins from me. When you keep ignoring the pain, the pain can become it's own problem. The skin discoloration could be a sign that your pain has been out of control too long. Prolonged pain can cause vasospasm (loss of blood flow) since the nerves feed the blood vessels. The loss of blood flow for too long can cause rebound increase blood flow which can cause skin discorations or ugliness!!! The vascular specialist would probably be the correct person in that scenario to see. 

During this first visit to the podiatrist he did x-ray my foot and said my joint had arthritis.  He gave me naproxen and sent me to have an insert made.  At that time the top part of foot over the big toe joint and then along the other toes was bruising.   Old looking yellowish yet darker in some spots.
Dr Blake's comments: Yellow, of course, is deep blood and the darker stains are the most superficial blood. Both of these colors are from the constant beating up on this or these joints. But, could indicate a bleeding problem. Please have some blood work including the standard CBC with Differential. 

 This bruising gets better and then worse when I hurt the joint accidently or wear shoes that are too soft.  Anyway, I never got the insert made.  This past year the pain has been getting worse.  This past weekend I wore new boots with the same heel as the other boots I wear.  I wore them around for around five hours and it got increasing more painful to walk.    When I got home my foot was throbbing.  I took off the boot and it felt like my joint was coming apart.  It hurt and the area around the joint swelled as well as my ankle.  I did walk though and by Monday the next morning it was somewhat better.  I was limping and it was really sore and I am yet today.
Dr Blake's comment: I know when you have something for a long time, you just want to ignore it and live life. However, this problem is crying out to be treated seriously, and you must start with creating a pain free environment for it, and keeping it pain free for 3 to 6 months. This probably will mean a removable cast, like the Anklizer, to reduce the bend in the joint. Perhaps just a shoe like the MBT will produce less bend to minimize the discomfort. In this task however, you should be armed with good protective orthotics and the skill of spica taping. 

Fortunately I had an appointment with the podiatrist that same day Monday.  Again I went in and he did x rays and said it was bone on bone.
Dr Blake's comment: Bone on Bone means that the cartilage (pillow) covering the bone is gone and the bone nerve endings are exposed. Pressure from the opposite side of the joint produces pain since the pillow is gone. Cartilage has no nerve endings, so in a normal joint you do not feel the joint moving. In an arthritic joint, with exposed bone on one side of the joint hitting exposed bone on the other side of the joint, the nerve endings produce a lot of pain with this pressure. 

 While examining my foot he asked me if I was diabetic.  I told him I was not.  He said my foot looked the way a diabetic foot looks.  He was referring to the discoloration/bruising.  I told him about the meds I take (nipedipine and hydrochlorthiazide) and what I thought some of the discolorations were along with injury.  He really did not say any more about that.  He then gave me three options.  Do nothing, joint replacement or fusion.  I asked him what he would do and he said if it was him he would probably do the fusion.  He set me up to have the surgery on November 15^th.
Dr Blake's comment: If you are pre-diabetic, signifying possibly poor healing, you need to get that checked out before any type of elective surgery. Check if your drugs for high blood pressure can cause easy bleeding. Definitely, you need you internist to work things up and make sure you can have surgery in the first place, or do you need to get your circulation, blood sugars, platelets, etc, evaluated?

I asked him if there was anything I could in the meantime meaning wrapping…something.  He said just carry on til then. 

That’s a long way away.  I have stairs in my house and my knee is making a sound/feeling every time I go from my room down to the living area.  I am limping up and down and not putting any weight on that area.

I don’t want surgery but I know something needs to be done because of the pain and the swelling.  Right now I want to call my podiatrist and ask him for a boot just so I don't have to hurt that area anymore but I am leery as he did not recommend this on Monday.
Dr Blake's comment: Doctors are human, at least some of them. You need to feel comfortable with any doctor who is making major decisions about the rest of your life. If you do not feel comfortable calling him, switch to another doctor. But, I would encourage you to stay with him and call. Doctors can not remember everything in the short time of the visit. Golden Rule of Foot: If a doctor does not discuss something you think is important, it is important, and they were just thinking of too many things at the time. So ask!!!

Do you have any ideas?  I want to walk again.  I want to exercise.  I feel like a cripple.  I am active though not athletic.   I hate the way the skin keeps being so discolored as if I broken bones.  Please give some me some advice.  I am wits end. 

The one good thing.  When I lay down I have no pain.  It's sore but it does not hurt.  But I can't lay down for the months or years...can I?  Nope got to work. 

Thanks for your time
Linda (name changed for privacy)

Dr Blake's initial response:

Linda, I will have more time this weekend to explore your email. Definitely you should be in a removable boot for the next 3 months while you analyze the pros and cons of various surgeries. I will help. I need photos of your foot, copies of your MRI and xrays. I prefer you cancel surgery while you really think this out. Rich You also need to have a good vascular workup to make sure you will heal from any surgery. 

 Hello again,

Thanks so much for replying.  

You do not know how much I do not want to let anyone see my feet.  I looked at pictures on your website and mostly their feet look healthy.  Mine look disgusting.  If only they could just look and feel halfway good i would be happy.   

I took two pictures with my cell phone.  Not good light.  I can get better pictures too.  

I also have a nail fungus which I asked the Podiatrist to treat, he wants to prescribe the antifungus meds which I refused at this time.  i wanted to read more about them.  And I wanted the joint pain taken care of first.

I can request xrays but never had an MRI on my foot.  

The tips of my toes are pink.  There is no bruising on any of them.  I wore open top shoes up to last month and both tops of my feet are discolored.  The right foot top is dark like a permanent tan but not bruised like the left.  The bruising was not as bad before I wore the boots on Sunday...anything constraining makes the swelling and bruising worse.  If I know it is nothing I can live with discoloration but what is causing it?  The damage to tissue? And i want to believe part of it is meds.  I also take synthyroid.  

I realize it is late and I don't expect any answers... I just have to ask the questions.

Thanks again

Linda

Dr Blake's response:

Hey Linda, So here are the steps you need to do if possible over the next few months. Get a vascular workup to make sure you do not have any bleeding problems that would interfere with surgery. Get an MRI to document the status of cartilage destruction on the joint. Get another opinion after these on the viability of conservative care vs joint cleanout vs joint replacement vs joint fusion. Definitely get into a removable boot with EvenUp, get orthotics that seem to place your weight into the center of your foot, learn to spica tape, and ice twice per day. I sure hope this has been helpful. Rich