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Tuesday, July 24, 2007

Stiff Big Toe (Hallux Rigidus) in active people - runners and other athletes

The most common site of arthritis in the foot is at the base of the big toe. This joint is called the metatarsophalangeal, or MTP joint. It's important because it has to bend every time you take a step. If the joint starts to stiffen, walking can become painful and difficult.

In the MTP joint, as in any joint, the ends of the bones are covered by a smooth articular cartilage. If wear-and-tear or injury damage the articular cartilage, the raw bone ends can rub together. A bone spur, or overgrowth, may develop on the top of the bone. This overgrowth can prevent the toe from bending as much as it needs to when you walk. The result is a stiff big toe, or hallux rigidus.

Hallux rigidus usually develops in adults between the ages of 30 and 60 years. No one knows why it appears in some people and not others. It may result from an injury to the toe that damages the articular cartilage or from differences in foot anatomy that increase stress on the joint.

Signs and symptoms

* Pain in the joint when you are active, especially as you push-off on the toes when you walk
* Swelling around the joint
* A bump, like a bunion or callus, that develops on the top of the foot
* Stiffness in the great toe and an inability to bend it up or down

Diagnosing the problem
If you find it difficult to bend your toe up and down or find that you are walking on the outside of your foot because of pain in the toe, see your doctor right away. Hallux rigidus is easier to treat when the condition is caught early. If you wait until you see a bony bump on the top of your foot, the bone spurs will have already developed and the condition will be more difficult to treat.

Your physician will examine your foot and look for evidence of bone spurs. He or she may move the toe around to see how much motion is possible without pain. X-rays will show the location and size of any bone spurs, as well as the degree of degeneration in the joint space and cartilage.

Nonoperative treatment options
Pain relievers and anti-inflammatory medications such as ibuprofen may help reduce the swelling and ease the pain. Applying ice packs or taking contrast baths (described below) may also help reduce inflammation and control symptoms for a short period of time. But they aren't enough to stop the condition from progressing. Wearing a shoe with a large toe box will reduce the pressure on the toe, and you will probably have to give up wearing high heels. Your doctor may recommend that you get a stiff-soled shoe with a rocker or roller bottom design and possibly even a steel shank or metal brace in the sole. This type of shoe supports the foot when you walk and reduces the amount of bend in the big toe.

A contrast bath uses alternating cold and hot water to reduce inflammation. You'll need two buckets, one with water as cold as you can tolerate and the other with water as warm as you can tolerate. Immerse your foot in the cold water for 30 seconds, then immediately place it in the hot water for 30 seconds. Continue to alternate between cold and hot for five minutes, ending in the cold water. You can do contrast baths up to three times a day. However, be careful to avoid extreme temperatures in the water, especially if your feet aren't very sensitive to heat or cold.
Source: American Academy of Orthopaedics
(This article then goes on to describe the surgical options)
Gary Moller comments:
This article is pretty typical of the advice given for arthritic toe conditions. For the athlete, the advice is inadequate, does not get to the heart of the cause and does not offer lasting solutions.

Sore toe joints is a common complaint in active people. It can come about as the result of a joint sprain or dislocation, such as happens when kicking or when the foot is trampled by a sprigged boot. It can also happen as the result of excessive repetitive repetitive stepping back and forth such as when doing Tae-Bo fitness classes. Accidentally stubbing the toe on a piece of furniture is another painful cause.

Joints require movement to be healthy. Without movement, the joint tissues are poorly nourished and they may consequently degenerate, causing a painful arthritic condition. If there has been damage to joint ligaments, such from a dislocation, the scar repair that binds the healing joint shrinks over time. If this is not stretched and mobilised during the healing process, the joint may be bound painfully together. Scar tissue shrinks over time and must be stretched and softened to ensure there is the restoration of normal function.

Wearing shoes all the time can contribute to the development of a painful rigid toe by restricting the natural movements of the feet. Feet, including the toes, are designed to be flexed and extended all the time to be strong and healthy. Shoes are no good for the feet if worn all the time. Lack of natural movement lays the feet open to the development of arthritis.

If you hurt a toe
So long as it is not broken, immobilise it for no longer than about 2 days. Using the healthy toe on the other foot as your guide, gradually work within pain limits to restore normal movement over several days. This should include careful traction to gap the joints.

If you have developed a rigid arthritic toe
This is where the fun begins and where I come into action! Forget about the injections, ultrasound, ice and surgery: By far the most effective way to fix an arthritic toe in an athlete is manipulation without anaesthesia. This can be extremely painful for the affected person. One woman described the pain as being more intense than child birth!

The purpose of the manipulation is to gap the joint that is bound tightly together by scar and unhealthy fibrous tissue, to break up any restrictive adhesions and calcification and to get some circulation back into the joint tissues.

There is no need for pain relief or anti-inflammatories. It may be a good idea to take some glucosamine and chondroitin and MSM to aid the healing.

While this procedure is agonising, the result after just 3-4 sessions is dramatic pain relief and full resumption of normal activity. Over the years, the results have been 100%

Ongoing maintenance of recovery includes getting about daily barefoot. Running and walking on sand is best for keeping the feet strong and healthy.

Please read my other articles about this painful and disabling condition (hallux rigidus).

If you have a problem with a stiff and painful toe, contact me directly.

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