Advice about self manipulating a sore big toe

For a few months I have noticed an intermitent sharp pain in my big toe. A podiatrist diagnosed hallux rigidus and pointed out the bump on the top of my foot below the big toe. He suggests X-rays and perhaps surgery. I have started using yogatoes every night and this eliminated the pain immediately, but not the bump. I tried emulating the massage you were doing as I watched your video. It seemed pretty straight forward, but you recommend getting treatment from a professional, and desisting from self treatment. What type of professional should I seek help from. Are you thinking of a chiropractor, or physical therapist or some other type of practioner? Thanks for posting the interesting video.

Mary

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Advice sought about toe pain (Hallux Rigidus).

"Hi Gary
I am a physician and also a runner. I have pretty awful rigidus on the left but I don't want to give up running. In fact, I'd like to do an ultramarathon in 2010.

All of the surgical options look crappy. None of the shots, NSAIDs, diet control, etc have been useful for me.

Thoughts?"

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Gary replies

Have you seen my video on toe manipulation? I learned this technique during a course in massage therapy by an American massage therapist to running greats like Arturo Barrios and other US athletes back in the 70’s and 80’s. 

This kind of toe injury is a common problem in long distance runners and more commonly nowadays in activities like boxing fitness classes due to the repeated slamming of the big toe into the shoe's toe box.  I should point out that the toe being manipulated in the demo video is in the final stages of recovery, since it had already undergone several sessions prior to making the video.....

Funny isn’t it: I have had no end of podiatrists writing in and complaining about this video.  A few are outraged.  The professors in podiatry say there is no real cure for this kind of toe pain other than surgery; I go and do a course with one of the best sports massage therapists around and he matter of factly responds to the question with a quick demonstration that consists basically of pulling the big toe! Granted most cases of Hallux Rigidus are not really Hallux Rigidus, so the Professors are technically right; but then again they are also wrong, if you get my drift.  Hallux Rigidus is the final stage of a progressive disease process and 99% of the cases I encounter are not true “Rigid Toe” – there is still some joint movement and these cases (Hallux Limitus) do respond positively to mobilisation.

The massage/manipulation can be very painful to do but the results can be dramatic within just a few sessions. It is really important to have several days recovery between sessions and to give it about 4-8 sessions to show improvement. In mild cases, one session is sometimes enough.

Surgery is the last resort and cortisone is such a crude instrument – bit like a US precision bombing raid – too much collateral damage to surrounding structures. I have had too many people come to me several months after cortisone injections with permanent damage.  Cases include a mate who’s entire plantar fascia avulsed a few months after a cortisone, ending a promising middle distance running career.

Go here to read my articles about cortisone and prepared to be shocked.

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Where can I find someone to massage and manipulate my sore toe joint?

"Hi Gary,
I saw your video and writings about this condition. I was recently diagnosed with this condition after an x-ray. The doctor told me he didn't seen much, if any, arthritis, but he said I have developed some bone spurring around the MTP joint. I agreed to try a cortisone shot. It helped for about 1.5 months and now the joint is becoming more painful again. He said that the spurring could continue to worsen if I don't get it taken care of surgically.

My question is whether you would agree, or would the manipulation technique you talk about help even with the presence of spurring? If you believe that manipulation would help, how would I go about finding a professional that knows this technique?

Thank you."
Mark
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Gary Moller replies:
Mark, your experience of coritisone injections is pretty typical of many active people: fast relief that does not last. Please read my growing list of articles here about the shortfalls of this kind of treatment.

The best way to deal with your kind of toe problem is as follows:

• Deep tissue massage and mobilisation of the affected joint and all the joints above and below as well as the rest of the foot and the lower leg. Do the other leg as well. This takes about an hour and should be repeated weekly for at least 6 sessions and probably ongoing.
• Replacement of tissue salts that strengthen the ligaments, joints and bones (CaFl, SiO2, CaPO4) - Active Elements 4.3
• Do a course of glucosamine and chondroitin with MSM taking the maximum dose on the label for 3 months and then reduce to an ongoing maintenance dose.
• Walk often barefoot on soft grass, in sand and in mud to flex, extend and strengthen the structures of the feet.
• Wear shoes that do not slam the toe box against the toes. This means lacing the shoes tight at the top and quite loose at the toe box part. If the feet slide about, change to a better pair of shoes. You could experiment with open shoes and sandals.
• Do alternative exercise to ones that slam the feet and toes - swimming, aquajogging, cycling, kayaking for example.

Where do you find a suitable massage therapist? If you live in Wellington I might be able to help. If not, then you have to shop around. You need a person with strong hands; but with the training and experience not to hurt you. I recommend, as a first start in your search, that you contact:

• Any Government accredited massage training institutions and ask for a recommendation of somebody in your area.
• If you have a professional or semi-professional sports team in your area, speak to the coaching staff and ask their recommendations. Ask top athletes you know of for their recommendations.
• Ask friends and workmates.

like any other kind of hands-on therapist, just how good a massage therapist is , is very much to do with your personal taste, their experience and style. You need to shop around and be prepared to stop and move on if it is obvious that it is not for you.

Effective deep tissue massage can be intense and painful at times and may leave you feeling quite sore for a few days after; but there is a difference between this kind of robust treatment and outright hurting you - this is a fine line that you and your therapist need to negotiate with care and skill.

As far as the spurring is concerned, the mobilisation involves pulling the joint surfaces apart and then gliding, rotating and bending the joint. The bone spurs which are at the very margins of the joints may get "ground" a bit and this can be agonising; but no damage is being done to the all-important articular surfaces of the joint. After several sessions, there should be a noticeable reduction in pain when this procedure is carried out. Not doing this, painful process risks the joint becoming completely immobile.

If surgery is finally required, nothing has been lost and much gained by having stronger, healthier feet going into surgery and the peace of mind of knowing you did your best with less drastic measures.



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Massage, hallux rigidus and a bone spur?

Hey Gary,

based on your experience, is it possible to use your massage therapy technique to help/cure hallux rigidus even when a bone spur has grown?

regards,

Max
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Gary Moller responds:

Max, Without seeing X-rays, it would be difficult to give a definite yes or no to your question.

However there should not be a problem: The idea is to traction the affected joint so that the ligaments are stretched and the joint gapped. The joint is then skillfully glided and rotated back and forth. There may be a little grinding of the joint margins which will be painful but the bulk of the joint will be completely unaffected. An experienced massage therapist will know how to go carefully and progressively and to gauge just how much pain is to be caused.

Each session should begin and end with massage of the whole foot and even the legs. Yes, there will be residual pain for a few days after but this should diminish with each weekly session. Take glucosamine and chondroitin at the maximum doses while undergoing this therapy.

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Email Gary: gary at myotec.co.nz (Replace the "at" with @ and remove spaces). Please include any relevant background information to your question.

Who can do the massage manipulation for a sore big toe?

"Gary,

I had some questions about the manipulation of the big toe? What type of professional can perform or would you suggest to perform the technique on the big toe?

I went to a podiatrists about almost 2 years ago, who took x-rays and stated I had Hallux rigidus in my joint. He stated that it could be from an old injury or hereditary which no one in my family has except bunions. I do remember this started when I was pregnant with my second son, and I do remember stubbing this toe and hurting for a little while. The podiatrists suggested some non movement shoes and prescribed anti-inflammatory. I tried taking the anti-inflammatory prescribed for about a week and it upset my stomach.

I absolutely hate taking medications if I do not have to, I only take maybe allergy meds on occasion p.r.n. He also suggested different foot wear, tennis shoes. I live in Florida and I can not wear tennis shoes around all the time in my house etc my feet would sweat!.... So I would like to try your alternative massage method which I think would work. I do have a bump on the top of the metatarsal joint which he said was arthritic.

My question is in the video you suggest someone professional to do this, Who might you suggest and the joint repair solution to use?

Any info would be great since I do experience pain... "

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Gary Moller comments:

I think the best professional to do the job is an experienced sports massage therapist. The massage/manipulation should be repeated every 4-7 days, once the toe has settled enough to repeat the procedure. After 3-4 sessions you should notice a significant improvement. Keep repeating the procedure until there is no pain of significance. If it does not improve after several sessions, then you should stop and review the situation.

I do not recommend taking anti inflammatoriescing the area. There are few situations that they should ever be taken. These drugs interfere with the natural healing processed within the body. While you may "recover" more quickly by popping these drugs, the resultant healed area may be weak and vulnerable to further injury. It is better to encourage and enhance the natural healing processes which the inflammatory process is part and parcel.

You do not need rigid shoes. Joints thrive on movement. Movement nourishes and polishes the joint surfaces. Encased in rigid and restrictive shoes causes stagnation of the joint synovium and consequent deterioration for the joint surfaces. You are better to get a good pair of walking shoes and rip out the inner sole and replace it with a pair of heat moulded Formthotics which support the feet without restricting their movement.

Get about bare foot and find a sandy beach and walk in the sand and shallows. Do not overdo this - ease into it a few minutes a day and gradually build it up as the feet adapt. Use the the same principles of physical conditioning as an athelte - hard day, easy day, hard day. So make every 2nd day a more or less rest day for the feet.

Nutrition is critical for proper healing: The first thing is to ensure that you have the right mineral balance. Please complete the Active elements Assessment here. I think you should also be taking a glucosamine and chondroitin supplement. You could also add some omega 3 oil. The best value is Waihi Bush Flax oil.

The idea is to start taking these nutrition supplements for about two weeks before you commence the toe therapy and continue for as long as there is any pain. While getting the toe workeed on, take the time to get a complete foot and calf muscle massage. chances are they are in need of some loving.

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Email Gary: gary at myotec.co.nz (Replace the "at" with @ and remove spaces). Please include any relevant background information to your question.

Hallux Rididus/Limitis - should I use orthotics?

I am a 31 year old semi-competitive runner and a police officer here in the US. I have been diagnosed with hallux limitis (stage 2). I am awaiting orthodics which I am told will take the stress off my great toe. I recently had surgery for a sports hernia which I believe is from a gait adjustment to avoid pain in my big toes. I have I have a family and have been really agonizing over giving up my running for good. However, I have implemented your massage technique today and am amazed at my increase in range of motion already. Would you suggest I still use the orthodics or just continue with the prescribed course of action on your web sight? I tried a 4 week comeback recently but had to stop due to big toe pain (causing a gait change again and painful hips!!). Any help would be appreciated.

Sincerely, Matt
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Gary Moller advises:
Matt, You are too young to retire from running. I never bother with orthotics which prevent the foot from working as nature intended. The nearest I go is Formthotics which are a heat moulded inner sole that supports the feet without interfering with their natural actions.

My advice is to give the massage plenty of time to take lasting effect. Three months doing the massage every 3-4 days with a break in between to allow recovery before ther next session.

Take a glucosamine and chondroitin supplement that has MSM added. Take the maximum dose every day for at least 3 months.

Get about barefoot as often as possible, including walking in sand at every opportunity. Look for a pair of shoes that simulate barefoot running, like the Nike Free. Start by walking in them and then wear them on runs of less than 30 minutes.

Resume running right away keeping within current pain limits and never running two days in a row - you must have at least one rest day between runs - even the short run - until you are completely recovered. Run a circular lap course rather than an out and back one, since Murphy's Law dictates that your toe will seize at the furthest distance from home. Run over varied terrain, preferably off-road trails. If you can't find anything suitable, come to New Zealand and train here.

Massage for a sore big toe and an acidic body

Gary I want to thank you for the great video you have on Youtube about massage as a treatment for this problem.

I am 53 and have had this toe issue for many, many years. I have never considered surgery or other allopathic treatments because of my own bias against those approaches. I am quite active (I install plumbing, radiant floor heat and solar systems) and play handball regularly. Last month I began twice weekly Traditional Thai Massage sessions with an excellent practitioner and have found these to be helpful for me in improving my overall physical health. I recently read your blog entry about the acidity issue and am considering reducing my sugar intake because I am guessing that also causes an overall alkaline/acidity problem.

Here's a brief question for you: Have you ever had success with reversing hallux rigidus with a person that has had this problem for more than 20 years?

Thanks again for sharing your knowledge. The reach and scope of the internet never ceases to amaze me.
Sincerely, Paul
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Gary Moller comments:
Paul,
The first step with regards to the acidity issue is to find out for sure if your body is acidic or not.

If your body is acidic then follow the guidelines for restoring as near to 7.4 PH as you can. An acidic body can be implicated in much chronic ill health, including feeling tired. This is common in people who work and exercise too hard. An acid body is recognised as a factor in osteoarthritis and rheumatism. While the focus has traditionally been on acid foods, the problem is more due to the body being under capacity in its ability to buffer acidity. A healthy body should have no trouble tolerating acidic foods such as citrus and tomato.

With regards to arthritic big toes, the answer is "No". Everyone I have personally seen have come to me well within 20 years. As with all health and injury conditions, the earlier one intervenes the better the prospects of a full recovery. However, just because you have had the conditon for 20 years does not mean you do nothing. It just means you must work more carefully and for much longer. And there may be more pain. While there may not be total relief from pain, the goal is to prevent further deterioration, if possible.

If your body is acidic, then deal with that by ingesting alkaline foods and a course of supplements like Floradix Magnesium. Support your joints with nutrients such as glucosamine and chondroitin, vitamin C and vitamin E. Get about barefoot in the sand and dirt and remain positive throughout.

thank you for posting your article and video on correcting foot pronation

Gary: I just want to thank you for posting your article on correcting foot pronation as well as you little video of the corrective exercise.
I was looking for just such an exercise to assist in building the arch of the foot.

I currently teach both my Yoga and Pilates students to "build the arch" for balance purposes. In fact I discovered this from yoga where it is called Pada Bandha. I have been using both the Mula Bandha (drawing up of the perineal floor) and the Uddiyana Bandha (lower transverse abdominis) to stabilize the core and begin activate the adductors. Activating all these and drawing up the energy from the arch of the foot corrects the pronation, helps to build the arch, stabilizes the knee, releases the hip and causes the glutes to be used instead of overusing the hamstrings. I found that when applied to running, not only was the spine in alignment and better able to absorb the shock, the feet came back into alignment and I no longer needed orthotics and did not get the Achilles tendon problems which had plagued me.

Thanks again and I am incorporating your exercise into my classes.

By the way, I love your country. My wife and I were there a month ago and just can't say enough about it.
Joe

Podiatrist tells Gary off - Hallux Rigidus has been misdiagnosed

Dear Gary Moller, My name is Daniel Bagnall and I am currently practicing Podiatric Medicine in Australia.

I would just like to alert you re: your treatment for Hallux Rigidus (fix it by manipulation), that this patient of yours has been misdiagnosed. I’m sorry to be so blunt but as a practitioner I find it very frustrating when the incorrect terminology is being used on the internet, please take the time to refer to the medical literature before posting such material:-

Normal dorsiflexion ROM at the 1st MPJ is 65-70 degrees ROM, this can clearly be observed at precisely 4:00 min in your video, pause and observe the position of the hallux, is the hallux flexing <65-70 style="font-size:130%;">
Gary Moller responds:
Thank you Daniel for pointing out that there appears to be no reference to the use of manipulation of hallux rigidus in the literature. This is one of the reasons why I produced the video. You will note that I advised in the video that this procedure be done by a professional (I assume from your writing in protest that you are not trained in this procedure).

I was first taught this technique about 25 years ago when undertaking a course in deep tissue massage by a sports massage therapist who made his living working almost exclusively on Olympic class middle and long distance runners mostly in the United States. At the time he was considered by many athletes to be the best. The simplicity and the effectiveness of this method in dealing with "impacted" toe joints, as we called them back then was astonishing. These kinds of toe injuries are common in runners and can be crippling to the point of being career-ending. I have never seen a failure of this procedure. Of course we are usually dealing with these injuries early (About Grade I-II).

You will also note in my accompanying advice with the video the use of nutritional supplements such as glucosamine and MSM to assist healing. I doubt you will find anything about this in the literature on hallux rigidus either; but that does not stop be advising the use of these supplements because they help expedite recovery.

As the literature (erroneously) states, this condition is progressive. The treatment offered in the literature does nothing to prevent progression which I find appalling. I can tell you that the condition is reversible in addition to being progressive, if gotten to early. This mirrors the view given to many other conditions. Take blood pressure for example: the usual medical approach only deals with the symptoms and the condition inevitably progresses. In most cases the condition can be reversed. As with the sore big toe, the sooner one intervenes with effective treatment, the more complete the recovery.

In the case of the woman in the video, you need to remember that her toe had already been manipulated several times. The toe in the video demonstrates remarkable restoration of mobility (She is naturally hyper-mobile in her fingers and toes btw).

If I was to obediently follow the guidelines in the literature, this healthy and athletic woman would be subjected to needless and costly medical treatment and eventual disfigurement by deliberate joint destruction surgery - the inevitable outcome of this kind of "progressive injury". We commenced about three months after the injury (So it was hardly acute!) and recovery has been quick and uneventful (other than the pain of the manipulation).

This procedure works very well on little toes as well.