I’ve been recently diagnosed with Hallux Limitus in my right 1st metatarso-phalangeal joint (the big toe). I’m currently getting about 20deg of deflection in that toe compared to 90deg in my left big toe. Pain originally hurt only after long training runs, but brought me to a screeching halt at IMWI this year (after a smokin’ swim and bike…bummer.) At this point, it’s painful to even walk down the hallway. X-rays are showing significant of calcium buildup around the joint, bone spurs, and not a whole heckuva lot of cartilage left in the joint. Being the typical Type A triathlete, I’ve been doing the online research on potential surgical treatments (cheilectomy, implant, fusing, etc.), odds of success (short-term and long), and recovery times. Was curious if anyone else has been in my situation, how they evaluated treatments and what the road to recovery looked like for them, especially in the context of training up for a 4-5 race 1/2 IM and full IM triathlon season? I’ve seen lots of commentary on similar bunion surgeries on ST, but nothing on my condition.
I’ll respond, although I doubt I will be much help to you; you seem quite advanced in terms of studying your problema nd examining the options.
My problem is a straight old bunion – pain on the inner side of the joint, which is enlarged. This has been visually obvious for several years, but with the exception of very sporadic (2-3x a year) and brief (less than a day) periods of soreness, it was never a problem – until after a half-marathon on Oct 23. It got progressively worse, then I stopped running for a month and did a ten-day course of a Advil a day, and it is now back to being okay, having survived recent runs of 6km, 8.7km, and 10km. I am, however, a bit concerned about next season, which was planned as a return to multiple half-irons. Before the half-marathon two months ago, it was never a problem on any HIM or IM or marathon, or anything long in training. But I’m soon-to-be-62, and this might be part of my landscape!
My doctor was very quick to dissuade me from contemplating surgery. He has worked with many, many runners over the years, and he’s seen several for whom the surgery did not work, the result of which is permanent toe soreness – much worse than the original condition. He would qualify that - maybe - for someone for whom the toe is already creeping under its neighbor, but in my case that’s not the case. (It was for my mother, however, so if these things are hereditary…)
If my pain persists or returns, he will give me a cortisone shot. At this point that is as aggressive as he wants to be with it. The way he describes the surgery and its prolonged recovery is very intimidating, even if it were to provide 100% assured success…so I can live with the more conservative approach for now.
Sorry I wasn’t more specifically useful to you; hopefully someone else will chime in with some better advice!
As I’m sure you know, hallux limitus/rigidus is a LOT different than hallux valgus (bunion) that the other poster mentioned.
Before contemplating surgery (and I do them all: cheilectomy, joint implant, distraction arthroereisis, osteotomies, arthrodesis, etc.), what else have you done? Simple NSAIDs (ibuprofen, etc.)? Joint steroid or Synvisc injection? Orthotic with Morton’s extension?
Surgery is based on surgeon’s preference and (at least for most) the Regnauld classification. Arthrodesis (fusion) certainly can alleviate pain and has a long history, but is that a good idea for an endurance athlete? Cheilectomy preserves the joint, but may be of limited value in someone at Stage III (that you sound like). I do not like (nor do very many) 1st MTP joint replacements. I’ll assume you have discussed your options with your surgeon and/or sought another opinion.
The condition’s been developing for about two years now, but only recently gotten to the point where it interferes with my training and competition…in that time, I’ve tried NSAIDS, training rest, icing, physical therapy, and the Morton’s orthotic. Have not gone the route of injections. At this point, it appears close to Stage III from what I’ve gleaned.
Discussing with two different surgeons right now, but wanted to get as many data points as possible from patients and practitioners like you as I decide which route to go. Trying to strike a balance between minimizing invasiveness and severity of surgery, maximizing longevity of solution, as well as still being a competitive triathlete on the other side.
You sound like a very educated patient and are going about it the right way. Most excellent.
Of course your criteria (“Trying to strike a balance between minimizing invasiveness and severity of surgery, maximizing longevity of solution, as well as still being a competitive triathlete on the other side”) is no easy task, but hits all the right bullet points. 1st MTP joint arthrodesis by far gives the best longevity (as you have likely read), but is certainly no easy surgery to recover from and will likely interfere with running at the level you probably want (but your current stage III HR might at this point anyway). Again, I’d rec against any type of joint implant (silastic, hemi or total). Cheilectomy works best in early stage III if your pain is mostly just the dorsal “bump”/spur type with shoegear irritation and NOT the quality of the joint motion or the joint itself. This is a relatively easy surgery and to recover from, but will NOT be long lasting and something will eventually have to be done later, but it does preserve the joint.
Best of luck in your ultimate decision - bumping for some personal anecdotes from the forum.
Was your Morton’s Extension rigid? Some nice carbon graphite options out there now that are heat moldable. They will limited extension of all MTP joints but are often tolerated better as sometimes a rigid morton may help limit extension, but sometimes can load the joint more due to bringing the ground reaction force medially under the 1st MTP still causing pain.
It is less predictable and its value is for a joint that is limited by dorsal impingement, but a cluffy wedge can be used to translate the proximal phalanx in a dorsal direction to its concave articulation glide on the MT head without compressing on the dorsal aspect of the joint which often shuts down from calcification/spurring… a simple manual distraction of the joint with a slight dorsal translation of distal phalanx while extending should yield > 20degrees (your limit) for this option to be viable.
You may be beyond these, but just thought I would chime in, if not for you than maybe for future searches.
I am also going through the same issues as you. I went to see my physio and in a few minutes of working on the toe I went from almost no movement in the joint to about 30%, we are now working to see how much more movement we can get through rehab.
I asked the podiatrist about whether running would make it worse and he said it may or may not, he mentioned perhaps getting an orthotic made with an extension on the big toe.
At this point I am wondering if contuning to run on it will cause more damage, I don’t have any pain unless it is cold or I run a long way and even then it’s only minor.
I wonder what options there will be 10 year from now to correct this?
I would also suggest contacting Dr. Mark Cucuzzella, a family practice doc, owner of a running store in WV, and is the coach of the Air Force Marathon team. He had a similar issue, surgery, and still runs 2:30 marathons. He is very responsive and can probably give you his experience and thoughts. E-mail is mark@freedomsrun.org
All - Thanks for all of the great feedback and experiences. I’m back at the surgeon next week for a more in-depth consult. Will bounce his findings against your feedback and my personal research.
I have/had Hallus Ridigus in both feet, had surgery to fuse the left joint in August and again to fuse the right in November. I was at stage 4 in both joints. I have a whole lot less pain now than before, I can swim and bike the same as before, running is with a much shorter gait than before since I can’t flex the toe as much anymore. There is a good article on this http://www.podiatrytoday.com/how-to-treat-hallux-rigidus-in-runners
I also need much wider shoes than before to be comfortable.
I had a cheilectomy just 7 weeks ago, so I can give you some feedback on the surgery and first few weeks of recovery since it’s fresh in memory. I was at about the same point as you are: significant calcium buildup & spurs, and not much cartilage left (stage 3). Pain started many years ago, and gradually increased every year. After 14+ races during 2010 including some trail runs and a half marathon, the pain had gotten to the point where it was changing my gait significantly and I was starting to have hip/knee issues from running off the outside of my foot. I was also in pain just walking around most of the time.
I evaluated all of the options and talked to two surgeons, one orthopedic surgeon who is a foot specialist and one podiatric surgeon who is a marathon runner. I decided on cheilectomy even though I know it’s only a temporary fix, and I decided to have it done by the podiatric surgeon. My reasoning was mainly that I wanted to preserve the joint as much as possible and increase the range of motion so I can squeeze a few more fast years out of my racing “career” (I’m 43 and still winning some local sprint / Olympic distance races overall). The increased joint mobility might even give me a shot at getting a little faster next season. If I can get 3-5 years of running with less pain, I’ll be happy. I figure I can still have the joint fused later when I’m older and slower and the joint pain gets unbearable again.
The surgery was quick and easy - in the hospital in the morning and out by noon. The entire forefoot was numb from the local anesthesia for the first 24 hours. When it started to wear off, I kept waiting for the serious pain that I had read about from others’ descriptions posted online, but it never came. I took some anti-inflammatories prescribed by the doc, but never needed the real painkillers. I was able to walk / limp using the outside of the foot from day one. The bandages came off after one week, and I found that I could get the foot into a Brooks Beast with the insole removed and the laces left loose in front - the toebox had enough room to keep the pressure off the toe. It was actually more comfortable than the surgical shoe. I was able to walk more and more during the second week - probably more than I was supposed to, but the joint still hurt so I had to walk on the outside of the foot. During the 3rd week, I started some short jogs during 1 or 2 mile walks, and by week 6 I was able to run (slowly) 3-4 miles every other day.
I’m now in week 7 and I still have pain, but it’s in different places like the bottom of the joint, and also the first toe joint (doc says that’s normal, part of the “re-adjustment”). The range of motion in the joint has increased significantly, but I still can’t use it fully while running. I think it will continue to improve, but it is already much better than it was before the surgery. I’m hoping to be ready for an Olympic distance tri in mid April.