"Severe" Hallux Rigidus... What now?

The orthotics are probably the best conservative option, with a Morton's extension. No reason to jump to a fusion, I typically perform an osteotomy (cut the 1st metatarsal and reposition it) and perform microfracture on the 1st metatarsal head to promote fibrocartilage growth. This typically allows runners to get back to running. The Podiatrist that I work with does an added step for those that are Stage IV, he will interpose some of the joint capsule.

Try the orthotics first though.

good luck

Brian

I concur with BFullem (Hello!). I have had 2 runners with similar problems get back to activity utilizing a moderate chielectomy with a shortening and plantarflexing osteotomy of the first metatartsal. Even I didn't think it would work as well as it did. Another recreational runner did great with a modified Keller Bunionectomy with interposed capsule, avoiding implants and osteotomies all together. Orthotics, properly made and with the Morton's extension should buy you time however.

To the two individuals who have already posted: thank you SO much for the advice/insight/info! Very surprised by such quick responses, and very encouraged to hear of the success (even to a surprising extent) of other runners that have been treated.

I do have three very specific questions, assuming this is your area of expertise (I'm assuming the two of you are legitimately associated with Podiatry and not merely trolls who decided to google some terms):

1) When you say that individuals could "return to running," at what level do you mean this? The reason I ask is because I am not (not to be insulting) just a casual jogger who logs a few miles a day: I am quite serious and am intent on qualifying for the OT Marathon in 2016 (posted low-2:20's marathon and a 1:06 half last time around). Doing so, I log a good bit of mileage (90-130 depending on the time of year and what type of races I'm preparing for). If operations such as the one's you have mentioned would "by me time" from the standpoint of another 5-10 years of logging 30 mile weeks, then, other than being able to run for the pure enjoyment of running, such prognosis would still be a dramatic change to my current running/career path.

2) I know it varies from person to person, but what would be your best guess as to how long I could expect to "by myself time" through the use of orthotics, if they do, in fact, help with the issue? Would I likely be looking at orthotics possibly helping me to continue training/racing at my current level for 2-3 more years, 5-10 years, 20 years...? Again, I do realize this varies from person to person, runner to runner, but by your best estimation from past experiences (as the two of you have indicated you have past experience with such issues) and bearing in mind the extent of use my feet must bear (90-130 miles a week), what would you guess the "lifetime" of such a fix to be?

3) IF orthotics do not wind up being my miracle cure and IF I am required to undergo surgery, but they are able to salvage the joint through means other than fusion or total joint replacement, what would a typical time-frame for full recovery be? That is, if you were to have an otherwise healthy, fit individual who had one of the operations you described above performed, how long would you estimate it would take from the day of operation until they were able to train at the level they had prior? My understanding from speaking with the Podiatrist I met with was that I would likely be off the foot, on cruches, unable to move it for 4-6 weeks, then following this period I could begin low-impact activities such as aqua-jogging or cycling. I'm curious - from your experience(s) - how long this period of limited to cycling/aqua-jogging would likely last before I could begin to incorporate light running? How long after this would you estimate the typical recovery is to return to full training? My assumption, based off the doctor's assessments, is that if I require an operation I will likely be unable to do anything for approximately 1-2 months at which time I could begin aqua-joggin/cycling to maintain fitness, aqua-jog/cycle for another 1-2 months before I could begin slowly incorporating light running in, gradually increase the running to several miles every day over another 1-2 month period, and once such a period is over, I could begin working towards regaining my former fitness.

Grand total, I'm assuming 5-6 months before I'd be able to consistently run 45-60 minutes a day, and another 6 months after that to slowly work my way back to ~100 mile weeks... so a good 12 months or so of minimal to no training. Does that sound about right to you?

Again, thank you so much for taking the time to read, respond, and give your insight! It is VERY much appreciated!

There are tons of different gismos and orthotics on the market for hallux rigidus. Some insist that it can be managed with the proper device. I have structural hallux rigidus (bone spurs) and can only move my big toe to about 20-30 degrees above the plane of my foot. I tried using a "cluffy wedge" (a/k/a kinetic wedge-google it). It is a little wedge that goes under your big toe to try to give you better range of motion by lifting the big toe up and allowing the joint to move better. It stunk. But, I turned it around and put it backwards under my 1st metatarsal in addition to a soft orthotic that I wear. That did wonders for my foot. It gave my foot just the right amount of extra support when pushing off to keep my foot from pronating too hard onto the 1st met joint. I have been training at about 60-70 mpw for @ 6 mos and have no signs of any progression in the hallux rigidus (ortho did comparison x-rays). There are a couple other orthotic gismos that you can try. It just depends on what can best control the motion in your foot that is overloading the 1st met joint and compensate for the lack of range of motion.

I would also recommend seeing a foot and ankle specialist MD who works with pro athletes or ballet dancers. Ballet dancers get hallux rigidus all the time from all the work they do on their toes. Pro athletes, especially footbal and soccer players, get turf toe, which is just another name for hallux rigidus. Podiatrists can do the surgery, but people who depend on their feet for their livelihood usually go to foot and ankle MDs.

I have heard that the surgery is risky. Sometimes the joint does not recover well and will get inflamed when returning to activity. I have also heard that recovery time is not to bad if the joint comes through in good shape. Kara Goucher had bone spurs and could not move her big toe at all. She had them removed and was able to start running about 6-8 weeks after the surgery. She dropped a baby a few weeks later and was back to racing in a few months after that. It is definitely possible to get through it in less than 6 months. But, if you can control it so that you can run well and stop the progression, it is better than risking the surgery.

None of my runners would be considered elite runners but 2 of them were more than just recreational runners. I do know an elite PSU All-American who underwent a hallux rigidus chielectomy and still competes quite well in his 50s. He is also a Podiatrist. The doom-sayers out there aren't always right. And I've never heard anyone recommend a Podiatrist just for the surgery and an MD for the non-surgical treatments! Not my recommendation at all. Proper podiatric orthotics often seem to be miraculous, although they sometimes won't work at all. It's worth the expense to try. The only harm would be to your wallet.

I have this too and the progression has been hell - my running has gone to piss as it has worsened. One toe in particular is hugely swollen (I now cut my shoe to accomodate the bulge) and I have nearly no motion in either big toe. I have tried real orthotics, gimmicks, and every ghetto homemade orthotic solution in the book (cutting a space for it in my insole to offload the 1st met, arch support, etc.). Went from being a sub 32:00 10k runner in my late 30s to struggling to run 34:00 in my early 40s (at altitude) without every getting out of shape or diminishing training (limping through mileage and workouts hoping for a miracle) and getting compensational pains and injuries and having people always ask why I am limping when I am out running. I am at the end of my rope and looking for a surgeon.

On the elliptical or a bike, I am still clearly in as good a shape as ever. But running is becoming plain no fun, and I have a ton of tolerance for frustration.

Stopped running at 23 due to hallux rigidus. What's the point of continuing? Your capacity to train is permanently diminished and you'll never perform be able to perform at your highest level. Meanwhile, running will accelerate the degenerative process and you'll eventually have pain that will keep you up at night and prevent you from doing basic everyday things. Which is more important to you, cranking out a few more years of sub-par running or being able to play with your kids in 10, 20 years?

Has anyone tried the Blade X-1? I just ordered a pair online.

I'm going through the same thing. Had run a few sub 32min 10k races, now just struggling to run. Was diagnosed with stage 3 hallux rigidus with bone spurs.

KMCalgary wrote:

Has anyone tried the Blade X-1? I just ordered a pair online.

I'm going through the same thing. Had run a few sub 32min 10k races, now just struggling to run. Was diagnosed with stage 3 hallux rigidus with bone spurs.

That is one of the gimmicks I tried and it hurt worse with it as it bends it a little bit constantly and you can't run in those things very well. It might work if you have more dorsiflexion than I have.

The best thing that has worked to let me keep running sort of is cutting a slot for my big toe (and, strangely, a small slot for the little toe) in a second insole and placing it under the first and I also use an arch support that I cut back a bit (since my pronation has gotten worse and late stage pronation is painful with hallux rigidus). You have better days and worse days and on the worse days it is hard to walk. Oddly running is less painful (but still awkward biomechanical accomodation) than walking.

I also cut away the shoe above the big toe knuckle and don't lace over it - I lace in a lopsided pattern that leaves no pressure on that joint.

I am to the point now where I am going to talk to a surgeon about my options as I just had a 7 week hip injury that was clearly compensational and got used to the idea of an extended period of cross training.

Any surgeon recommendations in the Boulder/Fort Collins area are appreciated.

Thanks again for all the replies!

One thing I would note is that I, too, have had some extreme lower back and hip flexor issues on my left side which I have often wondered if they were compensational issues related to some malady I had yet to locate. It seems as though severe hallux rigidus in the big toe of my right foot could explain it all...

Hi Brian,

Sorry for the questions, I'm still learning about this injury. Do you have bone spurs or do you have sesamoiditis (or both)?

My injury seems to be a lack of spacing, cartilage and bone spurs. One of the spurs broke off and is sort of floating. Surprisingly, I actually have a fair bit of movement left in the joint. I have two sets of x-rays about a year apart that show not much change in the joint.

I'm going to try to x-1 blades first before deciding on surgery. I've already notices that getting the swelling down a bit seems to lower the pain. My left foot has a 2.5cm larger diameter than my right.

I have bone spurs and sesamoiditis (although that pain has improved a bit with a 1st ray cutout).

While both of my toes are rigid (I can't move my big toes under their own power more than slightly), but I can take my hand and bend them a little bit with pain), my left foot is also a few cm wider (thick) from the toe knucle to the met head than the other.

I just made my appt for a surgery consult at Boulder Orthopedics after a few weeks of mulling it over.

Good luck with your surgery Brian. I hope it goes well. Please let us know how it goes.

A real pain in the... foot wrote:

Thanks again for all the replies!

One thing I would note is that I, too, have had some extreme lower back and hip flexor issues on my left side which I have often wondered if they were compensational issues related to some malady I had yet to locate. It seems as though severe hallux rigidus in the big toe of my right foot could explain it all...

Your first plan of action is this: SEE AN ORTHOEDIST WHO HAS DONE A FELLOWSHIP IN FOOT AND ANKLE!!! STOP SEEING PEOPLE WHO ARE ONLY QUALIFED TO REMOVE INGROWN TOENAILS!!!

Seriously, podiatrists are also qualified to help people with diabetic feet and a couple other things. They should not be performing surgeries that an orthopod should be doing! And you should be seeing a doctor that is a sports medicine/ foot and ankle specialist! MD stands for medical doctor. DPM stands for doctor of podiatric medicine. See an MD!

Brian wrote:

I have bone spurs and sesamoiditis (although that pain has improved a bit with a 1st ray cutout).

While both of my toes are rigid (I can't move my big toes under their own power more than slightly), but I can take my hand and bend them a little bit with pain), my left foot is also a few cm wider (thick) from the toe knucle to the met head than the other.

I just made my appt for a surgery consult at Boulder Orthopedics after a few weeks of mulling it over.

Good move! Seeing an ORTHOPEDIST!!! Not a podiatrist.

The key for surgery is going to a surgeon that you are comfortable with. There are good podiatrists and bad ones, there are good orthopedists and bad ones, just like all specialties.

Many newly trained podiatrists are coming out with easily over 1000 surgical procedures and three years of residency focusing on foot and ankle surgery.

Orthopods typically have a couple to few months focused on foot surgery during a five year residency, with an additional year if they do a foot and ankle fellowship. Some of the fellowships are done alongside....gasp, DPMs...hmm that is weird. Many ortho groups are even hiring DPMs to do all of their foot and ankle cases.

Definitely go to a foot and ankle trained ortho or a surgically trained podiatrist. Definitely go to someone that understands and works with athletes regularly and truly understands the demands.

intheno wrote:

The key for surgery is going to a surgeon that you are comfortable with. There are good podiatrists and bad ones, there are good orthopedists and bad ones, just like all specialties.

Many newly trained podiatrists are coming out with easily over 1000 surgical procedures and three years of residency focusing on foot and ankle surgery.

Orthopods typically have a couple to few months focused on foot surgery during a five year residency, with an additional year if they do a foot and ankle fellowship. Some of the fellowships are done alongside....gasp, DPMs...hmm that is weird. Many ortho groups are even hiring DPMs to do all of their foot and ankle cases.

Definitely go to a foot and ankle trained ortho or a surgically trained podiatrist. Definitely go to someone that understands and works with athletes regularly and truly understands the demands.

That is a joke. Ortho groups hire podiatrists because stupid patients schedule appointments with orthos for problems that a podiatrist can take care of: the easy, gross stuff that orthos do not do. That would not include procedures for hallux. Oh, unless the doc profits from it. Hmmm.

During the year of a foot and ankle fellowship a fellow may meet or observe a podiatrist but they are certainy NOT spending much time with them and are certainly not training "alongside" them. That is laughable.

See am MD. See an MD with lots of experience if that makes you feel good but see an MD!

I am done as people love to troll so much and I have fed you enough for a while, obviously you are and want to stay uninformed. You can google and look, if you know how to really use google you will be able to see everything else I said was true.

intheno wrote:

http://www.orthofootankle.com/fellowship-information/

I am done as people love to troll so much and I have fed you enough for a while, obviously you are and want to stay uninformed. You can google and look, if you know how to really use google you will be able to see everything else I said was true.

So, that link shows an institution that does fellowship programs for real doctors and for podiatrists. The doctors are surely learning about orthopedic problems and the podiatrists are learning about PODIATRIC medicine- there is a difference! Google that, idiot.

I happen to know one doc on that list- mathew Buchanan. He has a podiatrist in his practice and the podatrist practices PODIATRIC medicine and dr Buchanan does ORTHOPEDIC SURGERY.

Weirdly enough, he doin my surgery for hallux.