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TriGeek 08-23-2003 08:16 AM

Hallux Limitus
 
Any Runners out there already had or considering surgry for Hallux limitus of the big toe?

I am a long distance runner/triathlete geek with hallux limitus of the big toe right foot. Am told if I continue running I will destroy all the remaining cartilage in the joint and be stuck with hallux rigidus and no running. I have been wearing orthotics for 4 years to good effect but toe is becoming more inflexible and painful.

In the last 4 months I have had three completely different opinions on type of corrective surgery
required to enable me to continue running.
First, a high rent district Philadelphia hospital based Podiatric surgeon advises hemi implant of titaniuim.Thats all he does now for patients with this problem it is so efective. Second I saw a podiatric surgeon at a podiatric teaching hospital/University sports medicine foot/ankle institute in Phila. He said I require a decompression osteotomy in which an "L" shaped sliver is cut from the toe bone near but not out of the joint. He says its so successful its all they do now for this problem. He said the hemi implant will not hold up for long with running and I will have lost the joint irreversably doing the implant surgery.
Third I visit the most reputable Orthopedic foot surgeon in Philadelphia. He says I need a chilectomy...where they remove the excess bone tissue and about the top third of the ball of the joint to allow range of motion without cartilage. He said hemi implant wont last and as to the decompression osteotomy "Podiatric surgeons and orthopeic surgeons live in paralell universes".
Each of the three surgeons seems to have plenty of experience at the surgery they do for this problem...but how do I know which type of surgery to get? None of the three even peforms the type surgery of the other two perform.

None seem to have experience with patients who are serious runners. Are there any runners out there that have had surgery for hallux limitus? What kind? How is your running now?

[This message has been edited by TriGeek (edited 08-23-2003).]

[This message has been edited by TriGeek (edited 08-23-2003).]

szcbassoon 08-23-2003 06:23 PM

Hi,
I am not a tri-athlete but a tennis player that had surgery last year for hallus rigidus, a step worse than you have. I had no movement left in my big toe joint anyway, so my dr. surgically fused it, and I am back on the tennis court better than ever..and doing a lot of running. The pain before the surgery was awful, and now 4 months later, I can hit balls and run for 2-3 hrs. pain free. You have to do research I think, and decide what kind of motion is important to your sport. Good luck,
Sue

TriGeek 08-23-2003 06:35 PM

Thanks Sue.
It is news to me that it is possible to run with a fusion. That's real good news.You got a good result. I'm curious. Did you use a Podiatric Surgeon? or an Orthopedic surgeon?


szcbassoon 08-24-2003 11:36 AM

Hi Trigeek,
I had my surgery done by one of the best Podiatrist surgeons around, was referred by many folks, and he specializes in surgery and athletic surgeries.
I am very very pleased, although the 6 weeks non-weight bearing in a cast was difficult.
Good luck!
Sue

metatartus 08-29-2003 06:21 AM

I can relate to your frustration. I have been trying to decide how to treat stiff big toe for a year and half, with varying and conflicting opinions from an ortho foot surgeon and two podiatrists, as well as conflicting web info. My ortho says toe fusion--that it will take away pain, enable me to hike and run, quick healing time, walk out office in foot cast, drive right away. He would put in two pins and a plate. First podiatrist said a year and a half ago, do straight bunionectomy. I was skeptical since much of pain is in ball of foot. Second pod pursued sesamoid problem, eventually came around to bunionectomy recommendation after continually asking what the other pod and the ortho said (I kept saying, no, I just want YOUR opinion). Ortho, meanwhile, says I DON't have a bunion problem, just osteoarthritis, degenerated joint. Yesterday I went back to first podiatrist--he was perturbed that I had consulted two others and very brusque. This time he said he would do a Keller bunionectomy--removing all joint debris and cutting out a portion of toe bone, leaving a space that would fill with scar tissue. Possible downside is floppy toe, but you at least have motion. He said that Ortho surgeons push fusion for people over 50 (I am 60) cause they heal more slowly, but that he feels older fit people can heal the space left by the Keller procedure. I was ready to go for it till I came home and researched Keller on web and find that it's recommended for INACTIVE older people! Here's what one site says about fusion, implant, and Keller:
"""In young fit people, especially those doing heavy jobs, a fusion of the joint would be recommended. This removes the painful joint and stiffens it completely. 95% of people will get rid of their pain. However, the toe is stiffer than before and the choice of shoes is more limited. A few people will go on to get arthritis of the small joint in the middle of the toe after a fusion, but this is not usually troublesome.
In retired, active people, a plastic ("silastic") replacement of the joint may be offered. This gets rid of the painful joint and, unlike a fusion, keeps some movement. This makes it easier to walk and to choose shoes (though high heels are still not advisable). However, the joint may wear out and if it does the toe may become very inflamed again. This can be difficult to treat and another operation may be needed. This is why replacement is only advised in people who are not very physically active.
In an elderly person who walks very little, the simplest operation is simply to cut out the arthritic joint (Keller's procedure) and leave the toe a little floppy. This can be quite successful in people who walk very little. However, in the more active person the toe may remain too floppy......."""
Worse yet, the site of the Am. Coll. of Ortho Foot Surgeons says fusion requires 6 weeks in a cast followed by 6 WEEKS on crutches! Whom are we to believe??? I would be interested to hear of any further info you find and what you decide.Sounds as if our problems are similar, except I am interested in returning to serious hiking, not running, and my joint is probably further deteriorated than yours. Right now I am opting to stick it out, hoping to find some other way to improve joint health. Check out low-level laser therapy for chronic joint conditions. I found a great review of studies on this subject---search article in Australian Journal of Physiotherapy by Bjordal et al. You can do this therapy yourself with the simple laser pen pointers found in any computer store. See article for times and how to do it.


szcbassoon 08-29-2003 11:58 AM

Hi Metatartus,
Your post is interesting as I had the fusion because I was told it is the only good choice, I am young and very active, just as you have researched. The implant I understand will wear out, and although I was in a cast and crutches for 6 weeks the pain is gone and I can run better than before. I too had a complete arthritis of the joint and it was completely stiff anyway.
Good luck, I am certainly happy with my result.
Sue

metatartus 08-31-2003 06:26 PM

Well that is very encouraging. My ortho surgeon did say that he had a patient with fusion who was back running in a few months. They all seem to exaggerate the healing time, though. I could swear he said I would walk out of the fusion operation, be able to drive immediately, and he said nothing about crutches. If you get a chance I would love to know more about the healing process--what you did, what type of cast, could you drive, how about up and down steps, anything you learned in the process that you might do differently? I am definitely leaning toward fusion over that Keller procedure as the more I learn, the more this "floppy toe" probability bothers me. At least I know what a stiff toe is like--mine is basically stiff now; it's just that it's painful all the time. If it didn't hurt, I wouldn't have to have anything done. Thanks again for the info.

TriGeek 08-31-2003 07:09 PM

Hi Metatarsus and Sue,
I had a foot MRI last week on the referral of my orthopod.Apparently part of the motion limitation may be due to the soft tissue tendons-ligaments-muscles on the top of the big toe getting hung up on osteophytic (extra boney) growth on top of the toe near but not on the joint. He also believes he can learn how much cartilage is left from this image; thus enabling a better prediction of the success of the surgery.

Interesting you should be a hiker. I never noticed any serious pain running until a back packing trip on the AT walking rapidly with big strides.(I have since learned to take shorter strides, walk a little more slowly and pack ultralight.)

The only reason I stopped running in March was because the pain, which was quite bareable,began changing to include the ball of the foot down from the big toe and top of the foot down from the toe. My concern was further damaging the joint by running.

I am 58.I see the orthopod next week.Will post latest advice I receive.

Thanks for all your information Metatarsus and Sue.
TriGeek

TriGeek 08-31-2003 07:13 PM

Sue and Metatarsus,
Were you told what "Grade" your hallux limitus is? I was told grade III by podiatrist #1 and Grade II by podiatrist #2.Apparently the surgical treatment can vary based upon the degree of progression of the condition.What I conclude from that is, a flawed assessment of the grade, can affect the accuracy of the advice.
TriGeek.

szcbassoon 09-01-2003 04:54 AM

Hi Metatarsis,
Well let me see..actually tomorrow I go for my 6 mo. check up and my right big toe is better than ever. To answer your questions, I was non-weight bearing for 3 weeks, (yes, hopping on 1 foot only)..and in a foot only hard cast for 6 weeks. I did drive after 4 weeks with the cast and used crutches until the cast was off @ 6 weeks. Stairs I did on my backside until I could do light weight bearing @ 4 weeks. I stayed home from work for 4 weeks, and wish I could have stayed home 6 as it was tough getting around those 2 weeks with crutches.
I don't think i would do anything differently, I have a fusion of my big right toe with 2 tit. screws in it!
It was an inconvenience, but I am pleased can work out, play tennis, and yes go shoe shopping too!
Good luck, and keep us posted...
Best, Sue

metatartus 09-01-2003 05:19 AM

Stages:
No mention was made of stages--one of my complaint is that my doctors seem so "unscientific" in discussing my condition--I get most of my detailed info from the web. Here is some info on stages from a really good site--http://www.podiatry.curtin.edu.au/encyclopedia/halluxlimitus2/
Grade 1 : Functional Hallux Limitus
This is the primary stage of the degenerative process and is often associated with a hypermobile first ray foot type.
Available range of motion is close to normal (60-65dergrees) and symptoms may or may not be present. It is appropriate to introduce orthotic therapy at this stage if a family history of hallux limitus exists or if changes can be detected on X-ray.
This will slow or stop the progression of the condition.(Dananberg et al, 1996)
Manipulative therapy can be introduced as a prophylactic maintenance of ROM.

Grade 2 : Mild Hallux Limitus
In this stage, 35-55 degrees of dorsiflexion ROM is available at the joint. If radiographic changes are not evident then ROM may be restored with manipulation, short term NSAIDís and biomechanical alteration ie. Orthotic therapy.

Grade 3 : Moderate Hallux Limitus
15-30 degrees of dorsiflexion is available and marked joint space changes can be seen. Conservative management should be more aggressive to be effective.
Manipulation must be performed regularly (by the patient at home)
Heat therapy is applied before exercising the joint followed by ice application to reduce inflammation.
Immobilization of foot hypermobility using Low dye strapping and the instigation of NSAID therapy. If this treatment regime is successful then orthotic therapy is indicated.

Grade 4 : Severe Hallux Limitus.
Motion is less than 15 degrees and the joint space has severe osteophytic proliferation.
Motion is extremenly painful, therefore in this case, immobilization with Mortonís extension and appropriate footwear is indicated.

Based on the above I am grade 4, almost no motion

metatartus 09-01-2003 05:38 AM

Thanks for the healing info, Sue, very helpful and am glad you are doing so well. TriGeek, my problem began precisely on the hiking trail--in the Shen. Park. Got sudden severe pain on top of toe, had to remove boot and walk barefoot a mile to car. Just like that it began and it's been pretty much the same since, except that the pain moved also to the ball of the foot, causing the one podiatrist to pursue a possible sesamoid problem. I have had constant slight puffiness on top of the big toe joint toward the second toe also. Have always felt that maybe the boot bending just over the joint and irritating it triggered my pain. None of the doctors seemed interested in the fact that it began suddenly, not chronically, but surely that must be a clue to something. I had both an MRI and bone scan. MRI finding ruled out sesamoid problem, said "arthropathy of first metatarsophalangeal joint. Spurring on first metatarsal head, findings likely related to osteoarthritis" Bone scan report says "findings may relate to osteoarthritis" Not very informative!
I think the diagnostic procedures and treatment alternatives for big toe probs are dismally archaic. I am going to get on the phone to NIH this week and see what I can find. Surely there must be ways to regenerate cartilage. And also to better target whether ligaments and tendons are involved. I feel as if the surgeons sort of go in there and see what they can see and then proceed to fix what they can--seems a bit chancey. I am still trying to work with stretching, gait improvement, and whatever I can find to avoid surgery, but am tending toward fusion if it comes to that.

szcbassoon 09-01-2003 07:55 AM

Hi,
My toe was definately the last stage and I finally resorted to surgery after I couldn't even press the gas pedal on the car without getting shooting pains up my leg. Mr surgeon said when he got in there I had hundereds of bone spurs, and no cartlidge left. It is no wonder that running for a short ball on the tennis court and stopping suddenly would be awful! Cleaned out all the bone spurs, and fused. I am early 40's..
Good luck to you both! Hope you both find a great dr. and heal quickly.
Sue
Sue

metatartus 09-09-2003 05:21 AM

Sue, thanks for all your info. TriGeek, just wondering if you came up with any further insights after your recent orthopod visit, or have come to any decisions. Would really appreciate keeping in touch, as it sounds like we have exactly the same problem. One of the big mysteries for me is why it hurts sometimes much more than others, without any relation to having walked more or less. Do you find this to be the case? There was a time when it hurt awfully while trying to sleep; now that isn't as big a problem--but maybe because I've cut back on walking?

kittyon 09-23-2003 12:45 PM

I have been diagnosed with hallux rigidus stage 4. Unfortunately I have been given conflicting opinions as to treatment. One is a chliectomy and if that is not sufficient then it is a fusion or bio-pro hemi implant. These opinions obviously come form differrent doctors. From the correspondence on this healthboard there is consideable differences of opinion. Surgery is scheduled for late October. Does anyone know how long an implant lasts for an active tennis/golf player, who loves to shop.


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