Hallux Rigidus Surgery Complication: Email Advice

Hi dr blake, you were kind enough 2.5 years ago to give me good advice after my hallux rigidus surgery. I have been doing really well, though it was a long road. Been hiking and biking which I had given up. I now only wear dansko xp shoes and keen hiking boots with custom orthotics, but have started to get terrible pains in my pinky toes. It happens when I'm standing or walking - its a burning sensation, continues after I remove my shoes. My pinkies are very bunched and sort of curled - any thoughts or suggestions?

Regards,
Martha (name changed)

Dr Blake's comment: 

     Martha, or whatever name you are going by today, thank you for the kind words and email. Two common problems occur following Hallux Rigidus problems with or without the surgery. They both relate to our body's natural compensatory motion of moving away from a problem. So, if the big toe joint is painful, or limited in motion, or both, we can easily supinate and roll our body weight towards the outside of the body. This shift in body weight can stress the side of the foot where the pinky toe ( #5 ) lies. The pain can be just a strain of the tissue, or the signs of a Morton's neuroma starting (especially nervy are symptoms like burning, buzzing, tingling, etc). The treatment is typically related to metatarsal supports behind the weight bearing (see posts on Morton's neuroma and padding suggestions) prominences, and/or lateral wedging to prevent over supination (and I have many posts on supination treatment). Some of this you need to sense out. Do you feel like you are rolling to the outside, etc? Kinesiotape or Rocktape can be used to stablize the outside (see the blog on arch taping with Kinesiotape as a circumference wrap). Get small Hapad longitudinal metatarsal pads at www.hapad.com. Experiment with icing twice daily, neural flossing three times daily, and Neuro-Eze (buy online). Hope this helps you moving in the right direction. Rich

Cheilectomy Post Op: Email Advice

Good evening, I had the cheilectomy surgery Nov 6 2013

Dr Blake's comment: A Cheilectomy (also known as an arthroplasty) is basically a joint cleanup of the big toe joint when arthritic spurs and cartilage damage is noted. Like meniscal repairs and cleanups of the knee, it may be the precursor of a partial or complete joint replacement. 

I was making good progress I thought. Recently, I am having a lot of soreness behind the big toe actually the entire toe is sore and nerve sensations are occurring.  I limp because of this soreness. 

Dr Blake's comment: If you read the post on Good vs Bad Pain, you are definitely in the Bad Pain side of things. What can you do to help this? Some common changes you can make are: daily ice pack for 10-15 minutes three times a day, learning spica taping, wearing a removable boot or another stiff sole shoe any time possible for the next several months, trying to make yourself dancer's pads to off weight, and going to PT for advice and anti-inflammatory treatments. 

 I went for my check up 6 months  he said to get some insoles for my sneakers but I  wear a 2 inch heel at work.

Dr Blake's comment: There is some many factors involved in finding a comfortable heel to wear. You definitely want to go shoe shopping. Try 20 different pairs of 2 inch heels and you will find some much more comfortable than others based on stiffness, padding, volume, flexibility, etc. 

  He said I was pushing my toe down causing pressure from wearing this small heel. He is a Orthopaedic surgeon for the foot and ankle.  I don't have much cartilage left by looking at my X-ray.   I am very active with weight lifting and stair stepping everything bothers my foot.  Further Surgery I don't think I want.  It's been 6 months and somewhat worse than 2 months ago for some reason.

Dr Blake's comment: When you are in a flare, which is very common for this and many surgeries during the first year, it is important to figure out how to get out of the flare as soon as possible. If that means a removable boot every weekend and evening after work for several weeks, so be it. If it means icing 5 times daily, and a good dose of oral meds, and shoe changes and physical therapy, so be it. See if you can begin to experiment and find what seems to help at least some, and then take the additive approach of finding multiple things. Hope it helps. Rich

Wednesday's Article of the Week: Gait Changes Post Big Toe Joint Fusion

So many of my patients with Hallux Rigidus do not like the thought of big toe joint fusion, and I share that thought. I have only two patients in my practice and they are doing well post surgery. I present this article abstract to help with pro/con list we all create when trying to choose between different treatments. I would still recommend joint fusion in only small instances, but when I do recommend the procedure articles like this help me feel better that the patient will do well afterwards.

Below are the foot x ray images of my patient who is doing very well with her big toe joint fusion. The hardware is scary, but she is stable, pain free, and comfortable walking. She is 2 years post fusion by our podiatrist Dr Remy Ardizzone. Dr Ardizzone is very skilled at cheilectomies (joint clean outs) and implants, but felt fusion due to the severe joint arthritis was the best option. My patient is happy with the results.

http://www.ncbi.nlm.nih.gov/pubmed/17296132?dopt=Abstract

Hallux Limitus/Rigidus Post Op Email Advice

	Dear Dr. Blake, I am an active (swim, pilates, yoga, circuit train, walk) 52-year old female with severe arthritis in hands and feet. Three years ago I had cheilectomy with osteotomy on left big toe. Dr Blake's comment: The cheilectomy is a joint clean out of bone spurs and scar tissue and the osteotomy is to shorten the first metatarsal taking pressure off the joint.  This relieved pain for nearly two years. I wear MBT shoes most of the day, avoid heels over 2 inches, take NSAIDs, etc. Now having severe stomach issues. No more NSAIDs. Discomfort is near-constant. Dr Blake's comment: Switch to topical Flector patches or Voltaren gel for the top of the joint. And try to lay an ice pack 2-3 times daily on top of the joint for 10 minutes to keep the inflammation under control. You can go to PT and get 5 iontophoresis treatments with topical cortisone (dexamethasone phosphate).   I will try the taping procedure you recommend. Here is my question: I am scheduled for surgery July 18. Was leaning toward joint fusion, but wonder about joint replacement. Dr Blake's comment: This type of surgery is no difference than knee cartilage tears. 5-10 years of a good result is considered normal response. Even joint fusions have 15-20% poor outcomes, and you can not do much about. I can only give you my bias, but I prefer possibly a second clean out, or partial implant (like the knee), as your next choice. Before surgery, perfect the taping, make sure your orthotics are great, and calm the joint down with a removable boot for 3 months with PT if need be. You may be very surprised how well you do. Calming the joint down will definitely help you make a clear headed decision about the next surgery. If you decide on fusion, consider occasional cortisone injections into the joint first to at least cool the inflammation down while you get some opinions.  My doc will do either, but cautions that I will likely wear out the joint replacement in fewer than ten years, possibly a few as 5. I will then need another surgery. This makes me hesitate. Dr Blake's comment: Do not use possible future surgery as a reason to do a more permanent procedure. The KISS principle still applies here. Think of the possible stress on other body parts if you have the big toe joint fused. Nothing is easy. Go one surgery at a time.  Please offer your opinion. on Taping Supplies: Nexcare Product Stronger Than Kinesiotape for Foot Injuries Additional Info: Also had Morton's Neuroma removed. No cartilage remaining. Several bone spurs and cysts. Bone on bone with severe degradation in head of metatarsal. Dr Blake's comment: Can you send a photo of the same image from your MRI that I have placed here so I can look at it and it may change some of my thoughts? Side view of First Metatarsal showing great bone across the joint of a T2 weighted MRI. Hoping your taping procedure will save my right foot, which is several years behind the left! on Taping Supplies: Nexcare Product Stronger Than Kinesiotape for Foot Injuries Dr Blake's comments: I hope this helps. Rich

Hallux Limitus: Post Op Advice

Hello Dr. Blake,

My name is Julie and I came across your site while researching hallux limitus surgery recovery. 

I'm a very active 48-year-old (with a 4-year-old daughter) and decided to have the procedure with my  podiatric surgeon on April 27 after dealing with the disorder for three years and having tried everything—orthotics, chiropractic, acupuncture, you name it. 

I think the procedure went well, and though I know you can't comment on my case specifically, I'm wondering if given your experience in this area, if you can give me a sense of what you've seen with patients who don't show signs of immediate improvement (given normal healing time from the procedure). It's now 7 weeks out for me, and though I seem to have a bit more flexion than I did before, the pain is worse than it was before the surgery. My doctor was hoping to see more progress at my second post-op checkup two weeks ago, but she says to remain optimistic. I'm starting physical therapy next week.

I get the sense from what I've read that by this point, the patients for whom this surgery is going to "work" have less pain than before the surgery, but pain greater than before the surgery at this point is a sign that the procedure didn't "work." (Using the word "work" very loosely here, of course).

Again, I know you can't comment specifically. I'm just hoping you might have "anecdotal" input that could help me figure out the best way to move forward (I'm considering a cortisone injection after the 3-month mark if it's still painful). I want to have the best chance of getting the relief I had hoped for from the procedure.

Thanks so much in advance for any insights you could share.

Julie

Dr Blake's comment:

Dear Julie, 

     Thank you for emailing, and, of course, there are a hundred questions I could ask you. Please email what type of surgery they performed and I will add to this email over time. First of all, all these surgeries other than fusion create a lot of raw sensitive bone which takes 6 months to 2 years (or more) to heal. You must protect this new born baby of a joint, and avoid painful activities. The raw bone is very sensitive, and slowly gets less sensitive. The things in your court to help are controlling the inflammation (icing and contrast baths), avoiding bending the toe (stiff soled shoes, orthotics, carbon graphite plates, spica taping, removable boots, etc), and time. I don't consider an MRI for 6 months, but like to wait 1 year. Surgeons like surgery, shots, and casts. Try to create a pain free environment, and then gradually month by month increase your activity. 70-80% of these surgeries work great, but you can not judge the results during the first 6 months well. Avoid cortisone with a passion--at least for the first year, unless you are not functional day to day. First priority--create that pain free environment so that you can function day to day with 0 to 2 pain level. Hope this helps with focusing on where you are at. Rich

Hi Dr. Blake,

Thanks so much for your quick response on your blog--it made me feel so much better (I've been very demoralized about this whole thing, which I know doesn't help with healing).

To answer your main question: The surgery I had on 4/27 was a standard cheilectomy (no osteotomy). 

I have my first physical therapy appointment next Wednesday and haven't yet gotten the Dynasplint prescribed (don't even know what that is yet).

I think my main question to you based on your blog response is regarding motion: after the boot came off, my doctor instructed me to manually move my toe up and down at that main joint several times throughout the day to help increase ROM. I'm wondering how that type of joint movement squares with your advice to keep the toe mobilized. Also, more broadly: wondering how walking in regular shoes (or barefoot) is different from moving the toe manually.

Since I'm lucky enough to have you close by, I'm thinking I might make an appointment to see you after I reach my 3-month mark and have a post-surgery x-ray taken. 

Thank you again in advance for all of your help. It's such an inspiration to meet someone who is so obviously passionate about his work (and helping others!).

Julie

Dr Blake's comment:

Dear Julie, 

     The standard cheilectomy (basically shaving off all of the bone spurs, but leaving some damaged cartilage) is definitely what I would try first with painful Hallux Rigidus. Your two limitations to bending the joint is raw exposed bone and the ligaments that surround the joint can get stuck down to the new bleeding bone (called adhesive capsulitis). You will gradually create motion back into the joint with walking, then running activities, but first with self mobilization (I have a video on this and the Physical Therapist can review with you to make sure you are getting it right). Any range of motion device or technique that causes pain while doing will probably make you tighter in the long run. The Dynasplint has been around, but I am not familiar with it enough to comment. Please have the physical therapist measure the joint range of motion (dorsiflexion and plantar flexion) at every visit, and especially after 6 Dynasplint sessions, to document if the range of motion is improving or not. It is crucial that the same physical therapist measure the motion each time. Moving the toe manually will be best with the 4 directions taught in the self mob video. Walking will never get the plantar flexion range of motion better than the exercises. Too many things can make the dorsiflexion range of motion less if they irritate and produce pain. So, get back to thinking about the pain free environment we need to achieve. Remember your joint will help teach you what is good and bad for it better than any doctor, blogger, or other general rules being applied. Hope this helps. Rich