What is Hallux Rigidus & Your Options For Treatment

Dr. Meredith Warner is an orthopedic surgeon and founder of Well Theory, your resource for maintaining and promoting full body wellness and improving function as you age.

The MTP joint or the metatarsophalangeal is on of the most common sites of arthritis in the foot. Located at the base of the big toe, this joint is important because it must bend every time that you take a step. Once arthritis sets in and the joint begins to stiffen, walking can become particularly painful.

When two bones meet and move together, that is called a joint. The ends of the bones are coated in cartilage which is very smooth and allows motion. Eventually, this may cause reactive bone spurs to develop. In hallux rigidus a prominent spur will develop in the top of the bone and the joint. This spur prevents the toe from bending as much as it needs to when you walk; resulting in hallux rigidus or a stiff big toe.

Hallux rigidus generally develops in adults between the ages of 30 and 60 years old. While there doesn’t seem to be any scientific reason as to why it affects some individuals and not others, it is thought to result from differences in foot anatomy that increase stress on the joint. In addition, some specific injuries to the toe can damage the articular cartilage and cause hallux rigidus.

Symptoms:

  • Swelling around the great toe joint
  • Pain in the joint when active, especially when walking
  • A bump that develops on top of the foot at the joint
  • Stiffness in the great toe coupled with the inability to bend it up or down
  • Hallux rigidus often looks like a bunion

Diagnosis

If you begin to find it difficult to bend your big toe up and down or you are walking on the outside of your foot as a result of the pain in the toe, please contact us right away. Hallux rigidus is easier to treat when the condition is caught in the early stages of development. If you wait until the development of bone spurs that are visible in the form of bony bump on the top of your foot then the condition will be far more difficult to treat. However, it is still treatable with the right skills and technology.

Your doctor should examine your foot and will look for any evidence of bone spurs. She will also check the toe for mobility and to see exactly how much movement can be achieved without pain. X-rays will pinpoint the size and location of any bone spurs, as well as, the progression of any degeneration within the joint space and cartilage. X-rays are helpful to determine the overall architecture of the foot and to plan surgery or treatment.

 

Non-Surgical Treatment

Anti-inflammatory medications may assist in reducing swelling and easing the pain of hallux rigidus. Applying ice packs or taking hot and cold baths may also control the symptoms and reduce swelling and inflammation for short periods of time. Your physician will likely recommend wearing a stiff-soled shoe with a rocker or roller bottom design or even a shoe with a steel shank or metal brace. This type of design supports the foot while walking and also reduces the amount of bend in the big toe. Taping often helps. In addition, physical therapy can be very successful in treating this condition.

Surgical Treatment

Arthrodesis: Fusing the bones is recommended when there is severe damage to the cartilage. The damaged cartilage is removed and screws, pins or a plate are then used to fix the joint in a permanent position. The bones grow together over time. While this procedure has traditionally been the most reliable in terms of reducing pain, it is important to note that you will not be able to bend your big toe at all. Fusion should be a last resort procedure only.

Cheilectomy: This surgery is recommended for patients with mild to moderate damage. This procedure removes the bones spurs and a portion of the foot bone, so that the big toe has more room to bend. An incision is made at the top of the foot. It is important to note that while most patients do experience long-term pain relief after the surgery, the toe and the operative site may remain fairly swollen for several months post-op. When one has a cheilectomy it is expected that another treatment will eventually follow.

Arthroplasty: This procedure is best suited for patients who do not place many high impact functional demands on the feet. Arthroplasty is a joint replacement surgery in which the joint surfaces are removed and an artificial joint is then implanted. This procedure may relieve pain and preserve some joint motion. It is possible to remove one side of the joint or both sides. The surgery is successful for pain relief but often the will eventually need to be changed or revised.

Cartiva: Unlike traditional fusion procedures, Cartiva eliminates your joint pain without sacrificing the natural movement of the foot. The minimally invasive procedure places an implant, composed of a biocompatible organic polymer, that functions similar to that of natural cartilage. The procedure allows the foot full weight-bearing capacity shortly after surgery. Cartiva can be implanted with a block of regional anesthesia. Cartiva is a technology that is innovative and can reduce pain while preserving more normal foot motion.

Improve joint function and reduce inflammation with Well Theory. Try our Bone & Joint Health Multi to promote musculoskeletal health, and use our Hemp Cream + Spray to reduce inflammation and pain on contact.

How Plantar Fasciitis Slows You Down

Plantar fasciitis affects over 2 million people a year and is thought to be the most common cause of pain in the inferior heel. If left untreated plantar fasciitis can become a disabling long-term condition. Plantar fasciitis affects a patient’s level of activity and affect mobility.

The natural history of plantar fasciitis can mean pain lasts up to two years without proper treatment. If treatment is implemented correctly and in a timely manner the patient can return to their regular activities quickly.

Anatomy

The plantar fascia is a band of fascia that runs directly beneath the skin and subcutaneous fat on the bottom of the foot. The plantar fascia connects the heel to the front of the foot and supports the arch. Passively, the plantar fascia helps bear the weight of the body and some studies estimate it supports as much as 14 percent of the total load of the foot.

The plantar fascia is also important during gait because it elongates as you move throughout the motion. As the plantar fascia elongates or stretches it provides increasing support to the arch and augments foot movement/function.

Causes

Since the plantar fascia functions as one of the primary support structures in the foot is prone to being overstressed. Too much pressure or overexertion can damage or tear the tissue. People who are overweight or constantly on their feet are specifically susceptible to developing plantar fasciitis. Individuals with flat feet or high arches are also more likely to develop the condition.

People who participate in running or walking are capable of developing plantar fasciitis because of the stress placed on the feet during these activities. Many people who have heel spurs develop plantar fasciitis however heel spurs are not the cause of plantar fasciitis. Nonetheless, the size of one’s heel spur corresponds to the intensity of pain.

 

Symptoms

If you feel pain in the heel and/or arch as soon as you step out of bed in the morning you may have plantar fasciitis. Patients who suffer from plantar fasciitis often report pain after long periods of being inactive; for instance, heel pain after a long drive or after working at a desk. Pain can also begin after periods of heavy activity; this is likely due to the stressors placed on the structure.

 

Treatment

Simple home-based treatments can be effective in about 10 months for over 90 percent of patients struggling with plantar fasciitis. Reducing or stopping activities that make the pain worst can quickly reduce pain in most patients. However, over time inactivity is actually worse for the foot. Icing the heel three to four times a day can also be effective. Plantar fasciitis can be worsened if the muscles in the leg and foot are tight. Stretching and exercises can reduce pain and improve mobility. Physician directed treatment could further shorten healing time to one to three months.

Anti-inflammatory medication can reduce pain and inflammation as well. Supportive shoes and orthotics can benefit the plantar fascia as well and provide essential support. Night splints are sometimes recommended to wear as you sleep to stretch the plantar fascia as you sleep. Physical therapy is an excellent treatment for this condition. Occasionally injections are required. PRP therapy is also known to work for plantar fasciitis as well.

Surgical treatment is only recommended after 12 months of non-surgical treatment if the pain is still present. Plantar fascia release is a surgery some doctors recommend if you still have normal range of motion but continued heel pain. During this procedure the ligament is partially cut to relieve stress and tension in the plantar fascia.

Gastrocnemius recession is a surgery that lengthens the calf muscles to decrease stress on the plantar fascia. Tight calf muscles increase tension in the plantar fascia and gastrocnemius recession aims to reduce the amount of stress caused by plantar fasciitis. It is the goal at Warner Orthopedics to avoid surgery for plantar fasciitis if at all possible.

 

For more information about Plantar Fasciitis visit the American Academy of Orthopedic Surgeons.

What to do if You’re Still Dealing with Pain after Bunion Surgery?

Unfortunately, bunion surgeries are not always successful. In the scientific literature on this subject, there are different types and severities of bunions; there are about 130 described ways to operate on a bunion. Usually, when there are this many options, it means that the best option has not been discovered. Historically, bunion surgeries have been painful and often fail.

A successful result from bunion surgery should mean that the patient is better and they have also increased their function. In addition, the patient should be able to wear the shoes they want to wear, such as high heels. A good bunion surgery will also allow the patient to walk relatively soon after the procedure and return to work quickly as well.

Revision Surgery

If you have had a surgery for a bunion and find that you still have pain, or that it has moved, you may benefit from what is called ‘revision’ surgery. Revision surgery simply means that the previous surgery is changed or revised.

The goal of a revision bunion surgery is to achieve the successful result described above. This type of surgery is complicated and requires a significant amount of training and experience to do well.

A patient’s radiographs and any other imaging must be analyzed and measured, and the foot anatomy and relationships between the various parts must be carefully examined. The foot doctor or surgeon should understand fully the patient’s activity levels and work description before planning the appropriate surgery.

Post-Surgery Transfer Metatarsalgia

Many patients have pain under the second and third toes at the ball of the foot after a bunion surgery. This pain is usually with activity and can be burning, aching or throbbing. Sometimes there is swelling there as well.

This type of pain is called ‘transfer metatarsalgia’; this basically means that the pain was simply moved from the bunion to the area under the ball of the foot; pain remains, even after surgery.

Many times this pain happens after bunion surgery because the bone for the great toe was shortened a little too much during the correction of the bunion. The shape of the foot is changed, and the patient’s weight moves over to the next toes during walking. The bones for the second and third toes were not designed for bearing so much of the body’s weight and they react with pain due to stretching out and compression of the tissues around these bones.

For this problem, a revision bunion surgery would create the normal balance in the foot again through a complex process of lengthening the appropriate bones.

 

Surgery should not be considered lightly.

However, if a patient has undergone surgery and feels that they still have too much pain, a consultation is in order to determine if revision surgery is necessary. There are surgical and non-surgical options available that can help to alleviate bunion pain, even if you have already had surgery.

What’s the Best Treatment for Plantar Fasciitis?

A recent study from McGill University in Canada looked at treatments for plantar fasciitis. The authors compared three groups of patients with pain from plantar fasciitis; each group had a different treatment.

The Study

  • One group underwent extracorporeal shock wave therapy (ECST) with orthotics and a home exercise program 
  • One group had a low-level laser (LLLT) with orthotics and a home exercise program 
  • The last group received only orthotics and a home exercise program 

Treatment Plans

  • The ECST group had to undergo shockwave treatment weekly for three weeks  
  • The LLLT group had to have treatment three times a week for ten sessions 
  • The last group did not have to go to a clinic for treatment 

The Results

The insoles that each group wore were non-custom and shock-absorbing. The exercises were heel cord (calf) stretching and plantar fascia stretching.

The participants were monitored in the three months following their treatments.

All three groups had a reduction in pain.

However, the LLLT group did the best in this study. LLLT and ECST have been recommended to increase cell activation and to stimulate healing. In this particular study, there was no additive effect of going to the clinic for ECST as opposed to simply wearing the orthotics and doing the exercises. However, the LLLT group did have an additive effect. That is, the LLLT therapy group had the most reduction in pain in this study.

The issues with both ECST and LLLT are that neither are covered by insurance and require multiple visits. Also, shock wave therapy is known to be painful. It is up to you to decide if such treatments are worth it for a modest improvement in pain control over conventional therapy, exercise, and insoles.

Cinar EE, Saxena S, Uygur F. Combination therapy versus exercise and orthotic support in the management of pain in plantar fasciitis: A randomized controlled trial. FAI. 2018; 39(4): 406-414

What is Ankle Arthritis?

The manifestation of ankle arthritis causes as much psychological and physical damage to the body as does the arthritis of the knee, hip, and back. In addition, we now know that ankle arthritis also causes as many functional limitations as does arthritis of the knee and hip.

However, ankle arthritis is only recently being recognized nationally as an actual pain source and entity worthy of treatment. Ankle arthritis has been considered secondary to hip and knee arthritis for a while.

Dr. Warner has been treating ankle arthritis for over a decade and is up to date on all cutting-edge treatments.

An unstable ankle due to ligament damage (sprains) that heal improperly can cause enough shear force to an ankle to produce arthritis. Also, a previous break/fracture will have abnormal motion if it is not repaired anatomically and that leads to abnormal forces on the cartilage; thus arthritis develops. It is very important that ankle fractures be corrected with exquisite attention to detail and anatomy.

The ankle is a small and perfectly shaped joint; it was not designed with the same amount of give and play that the knee and hip have. Therefore, fractures of the ankle have many more long-term consequences with regard to arthritic change.

Fractures that cause significant cartilage damage lead to ankle arthritis.

More often, fractures that heal poorly or heal in a poor position lead to arthritis. This is because even a 1mm shift in the ankle joint surface can dramatically increase the contact pressures inside the joint and cause chondral damage (arthritis). Again, this is not true for the hip and knee.

A mal-united fracture can be corrected to either prevent or treat arthritis. If you have an old fracture that has healed in a bad position, there are a number of treatment options available to correct that problem.

 

Causes of Ankle Arthritis

About 1% of the adult population has ankle arthritis. Of those, 80% are post-traumatic in nature. The ankle is different than most joints in that the arthritis is typically due to trauma. Most other joints, such as the hip, knee, and back have degeneration as the primary source of arthritis. The ankle breaks down and becomes arthritic after either a fracture (broken ankle) or due to sprains and ligament damage. For post-traumatic arthritis to occur, the actual bony plate that the cartilage sits upon must break as well as the cartilage itself.

Most cases of late ankle arthritis also have an alignment problem; that is, the ankle is in a varus or valgus position (tipped inward or outward). The mal-positioning of an ankle increases abnormal forces and also instability at times; this is associated with arthritis and pain. Any treatment plan should include a correction to normal alignment. If your treatment plan for ankle arthritis does not, ask your doctor if he or she has considered that.

 

Diagnosis Process

Pain is often associated with arthritis. However, some people with arthritis have no pain at all; it is not predictable who will have pain or who won’t. Many times other factors play into the perceived pain beyond the actual arthritis that is present. Ankle arthritis is no exception to the association of arthritis and pain; typically ankle arthritis hurts during activity (work, walking, running, etc.). Occasionally pain occurs with changes in the weather or after activity. Sometimes pain is spontaneous. There is a genetic predisposition to chronic pain related to arthritis. Cartilage itself has no nerve endings and arthritis in and of itself cannot be painful.

The pain that is associated with arthritis is typically due to associated damage to the bone that the cartilage sits upon, the synovial tissue or joint capsule and the ligaments around the ankle. In addition, the muscles of the leg can hurt, as can the nerves that surround the joint. The inflammatory fluids that are released due to the inflammation can sensitize nerves; this may contribute to pain as well. It is important that the actual source of pain be recognized prior to beginning or selecting any treatment method.

Just because there is the presence of arthritis on an X-ray and the pain is at that joint does not necessarily mean that there may not be another source of pain. Diagnosis of actual pain source should be mandatory prior to any surgical intervention.