Pain or discomfort in the great toe joint is a common occurrence amongst people seeking podiatric treatment. There are numerous reasons why people may experience pain or discomfort in this region. Pain in this area may be due to a restriction of motion, a condition referred to as hallux limitus or rigidus. This condition can lead to jamming of the joint and potential degenerative joint disease or arthritis. Ironically, this will lead to even further stiffening of the joint and pain with walking. Bunions or hallux abductovalgus deformities can also cause pain in the great toe joint. After years of this abnormal alignment of the joint arthritic changes can occur causing even more pain. Prior injury to the joint can lead to the development of traumatic arthritis. This is another potential cause of pain in the great toe joint. Patients with diabetes may develop an altogether different problem related to this lack of motion. In the presence of peripheral neuropathy (lack of painful sensation), these patients can develop skin breakdown and ulceration.

As you can see there are numerous causes for a painful joint. There are also numerous options, conservative and surgical, to treat these conditions. A Keller Arthroplasty is a surgical procedure designed to eliminate pain and discomfort in this joint. It is typically reserved for cases of severe arthritis, previous failed surgeries, diabetic ulcerations or certain types of bunion deformities.

Indications For Surgery

As with all surgical procedures there are certain criteria that are followed in choosing one procedure over another for any individual patient. In the case of the Keller arthroplasty, it is most commonly reserved for patients over the age of 55 with limited athletic activity. These patients are best able to tolerate the alteration in toe function created by this procedure. There should also be a moderate to severe amount of pain on movement of the joint, either passively or with walking that is not relieved by shoe gear, orthotics or other non-surgical means. X-rays are helpful to evaluate the condition of the bone and joint. These may show joint space narrowing, bone spurs or joint deterioration. As with any surgery, it is important that the patient have a clear understanding of all available options. They should also be aware of what to expect after surgery.

The Surgical Procedure

The procedure itself is fairly straightforward. An incision is made over the great toe joint. Once the joint is exposed, a small portion of bone is removed from the base of the proximal phalanx. This allows for an increase in motion in the joint and a reduction in pain. The defect created by the removal of the bone will fill in with soft tissue, creating a “false joint”. Some surgeons may choose to place a pin across the joint to maintain the position of the toe and to allow for scarring. The pin is usually left in place for 3-4 weeks. The soft tissue structures are then re-attached and the wound is closed. The patient is then placed in a surgical shoe. Casting is not necessary and limited ambulation is usually allowed following this procedure.

What to Expect after Surgery

The postoperative recuperation usually involves use of the surgical shoe for 2-3 weeks. Limited ambulation may be allowed. If a pin was inserted, this is usually removed after 3-4 weeks. Because the pin exits out the tip of the great toe, it can usually be removed in the office. It does not require a second surgical procedure. Once the pin is removed, the patient can get the foot wet, increase their weightbearing activities, begin range of motion exercises and gradually advance to sneakers. Most people can return to their usual shoe gear and activity at 6 weeks.

The most common postoperative concerns are prolonged swelling. It is not unusual for some degree of swelling to persist beyond 3 months. This will typically resolve on its own. Occasionally, the use of a compression sock will expedite resolution of the swelling. Also, an orthotic device may be helpful to allow for more efficient transfer of weight during ambulation and more even distribution of weightbearing forces. All in all, when the preoperative criteria are met, this procedure can provide a significant degree of relief from a painful great toe joint.

Hammertoes Treatment in Issaquah, WA

Hammertoes are a contracture of the toes as a result of a muscle imbalance between the tendons on the top and the tendons on the bottom of the toe. They can be flexible or rigid in nature. When they are rigid, it is not possible to straighten the toe out by manipulating it. Frequently, they develop corns on the top of the toe as a result of rubbing on the shoe. They may also cause a bothersome callous on the ball of the foot. This occurs as a result of the toe pressing downward on the bone behind the toe. This area then becomes prominent and the pressure of the bone against the ground causes a callous to form. (Corns and Calluses)

They tend to slowly get worse with time and frequently flexible deformities become rigid. Treatment can be preventative, symptomatic or curative. (For information on hammertoe of the big toe see Hallux hammertoe)

Preventative treatment of hammertoe is directed toward the cause of the deformity. A functional orthotic is a special insert that can be prescribed by your podiatrist to address the abnormal functioning of the foot that causes the hammertoe. Functional orthotics can be thought of as contact lenses for your feet. They correct a number of foot problems that are caused by an abnormally functioning foot. Our feet, much like our eyes, change with time. Functional orthotics slow down or halt this gradual change in the foot. Often when orthotics are used for flexible hammertoes, the toes will overtime straighten out and correct themselves. Calf stretching exercises are also helpful. Calf stretching can help to overcome part of the muscle imbalance that causes the hammertoe.

Symptomatic treatment of hammertoes consists of such things as open toed shoes or hammertoe pads. There are over the counter corn removers for temporally reducing the painful callus often seen with the hammertoe. These medications must be used with caution. They are a mild acid that burns the callus off. These medications should never be used for corns or calluses between the toes. Persons with diabetes or bad circulation should never use these products.

Curative treatment of hammertoes varies depending upon the severity of the deformity. When the hammertoe is flexible, a simple tendon release in the toe works well. The recovery is rapid often requiring nothing more that a single stitch and a Band-Aid. Of course if several toes are done at the same time, the recovery make take a bit longer. For the surgical correction of a rigid hammertoe, the surgical procedure consists of removing the damaged skin where the corn is located. Then a small section of bone is removed at the level of the rigid joint. The sutures remain in place for approximately ten days. During this period of time it is important to keep the area dry. Most surgeons perfer to leave the bandage in place until the patient's follow-up visit, so there is no need for the patient to change the bandages at home. The patient is returned to a stiff-soled walking shoe in about two weeks. It is important to try and stay off the foot as much as possible during this time. Excessive swelling of the toe is the most common patient complaint. In severe cases of hammertoe deformity a pin may be required to hold the toe in place and the surgeon may elect to fuse the bones in the toe. This requires several weeks of recovery.

Complications associated with the surgery are infection, excessive swelling leading to delays in healing and potential deviation of the toe. If excessive bone is removed during the surgery, the toe may be a bit floppy. The toe always has a floppy feeling for several weeks following the surgery. This is normal and generally not permanent.

If pinning the toe is not required during the procedure, then the surgery could be performed in the doctor's office under a local anesthesia. Some patients perfer the comfort of sedation during the surgery and if this is the case or if a pin must be placed, then the surgery could be performed in an outpatient surgery center.

For a proper diagnosis and recommended treatment plan, we suggest you consult with a podiatrist for professional help and care.

Hallux varus is a condition in which the great toe is pointing away from the 2nd toe. This can be considered the opposite of a hallux valgus or bunion deformity. In contrast to a bunion, however, the 1st metatarsal remains in its anatomical position while the great toe is deviated towards the middle of the body.

Hallux varus most commonly occurs as a complication from bunion surgery. However, other causes can lead to this condition. These include: congenital deformity, tight or short abductor hallucis tendon, trauma, absence or surgical removal of the fibular sesamoid.

The presenting symptom is most commonly pain. This can occur from the toe rubbing against the side of the shoe. Occasionally, this deformity can also lead to problems with ingrown nails as the nail fold is pushed into the nail border by the shoe.

Diagnosis

The diagnosis of hallux varus is fairly simple as the great toe can be seen to be deviated away from the 2nd toe. A careful history will often assist in determining the cause of the hallux varus.

This is a condition that is not uncommon in children. A congenital deformity is most commonly the result of a tight or short abductor hallucis tendon. This tendon attaches to the side of the great toe. It opposes the pull of the adductor hallucis tendon that is on the opposite side of the great toe. By working together, these tendons assist in keeping the great toe straight. However, when the abductor tendon is tight, it will overpower the adductor tendon and pull the toe toward the midline of the body. The diagnosis can be made by attempting to reduce this deformity manually and feeling the tightness of the tendon.

Trauma should also be considered as a possible cause of this condition. Injury to the great toe, which disrupts the mechanical balance of the tendons, can lead to this abnormal deviation of the toe. A careful history and clinical examination will often lead the physician to the correct cause.

The fibular sesamoid is key structure in the development of a hallux varus. Because the adductor hallucis tendon attaches to this structure, any disruption of the fibular sesamoid can lead to a hallux varus. This can result from a condition referred to as agenesis of the fibular sesamoid. In this condition, the fibular sesamoid fails to develop from birth. Therefore the normal attachment of the adductor tendon is absent, causing the abductor tendon to pull the toe medially. Trauma to the sesamoid which disrupts this attachment can also lead to a hallux varus (see sesamoiditis). One of the more common etiologies however is when a fractured fibular sesamoid needs to be removed due to non-union and chronic pain. Surgically the attachment of the adductor tendon is disrupted when the fibular sesamoid is removed.

The most common cause of a hallux varus, however, is following a bunionectomy. This fortunately is not a common complication of bunion surgery. This most commonly develops as a result of: 1) aggressive removal of the "bump" on the side of the great toe; 2) removal of the fibular sesamoid; 3) over tightening of the soft tissues medially as one corrects the deviation of the toe.

Treatment

Treatment of this condition is dependent on the cause. In children with a tight adductor tendon, treatment should be focused on stretching this tendon. This can be done with stretching exercises, splinting of the toe and straight or reversed last shoes. If conservative care fails to correct the deformity, surgery may be necessary. This is performed by selective sectioning of the tendon with a small incision on the side of the toe. The toe is then splinted in a neutral or straight position.

When hallux varus develops as a complication from bunion surgery, additional corrective surgery is often necessary. The extent of the surgery will depend on the degree of the deformity and the length of time the hallux varus has been present. The earlier the hallux varus is discovered and treated, the less complicated the corrective surgery.

This tumor was once thought to be a cancer of a tendon sheath. It is now known to be a benign non-cancerous tumor of a tendon sheath. These masses are generally found on the toes, top of the foot or sides of the foot. They are always closely associated with a tendon sheath. They can also occur deep inside the foot. They slowly enlarge but never grow any larger than 4cm in size. They are firm irregular masses that are commonly painful. The pain seems to be a result of the tumor pressing firmly on the surrounding tissues and due to the interference with the function of the tendon that the mass is growing from. As the tendon grows it can press so firmly on the bone it lays next to, that it can cause erosion of the bone. It is because of this erosion of bone that the tumor was once thought to be cancerous. Cancerous tumors can have the characteristic of invading bone through aggressive and destructive means. The erosion of the bone associated with giant cell tumors is due to pressure on the bone and not due to the invasion of the bone by the tumor. Other common soft tissues masses that may occur in the foot are ganglions, fibromas.

Diagnosis

The diagnosis of a giant cell tumor is generally made by a pathologist following removal of the mass. Clinical history of the mass may give the surgeon an idea of what they might expect when removing the mass. X-rays may show the shadow of the mass, and in 10-20% of the cases, may demonstrate bone erosion. The mass is firm and nodular, and always connected to a tendon. A MRI may be useful in determining the extent or size of the mass.

Treatment

Treatment of giant cell tumors is the excision of the tumor. Some physicians may attempt to inject the mass with cortisone in an attempt to shrink the mass.

The Procedure

The surgical excision of giant cell tumors is generally performed in an out patient surgery center. Depending on the location of the mass the surgery may be performed under a local anesthesia, with intravenous sedation or general anesthesia. Following administration of the anesthesia an incision is placed over the mass. The mass is then carefully dissected free from the surrounding soft tissues. Following the closure of the surgical site a gauze compressive dressing is applied. Depending upon the location of the mass the surgeon may apply a splint or below the knee cast. In some instances the surgeon may perfer that the patient use crutches for a few days or for as long as three weeks.

Recovery Period

The recovery period depends upon the location of the mass and the extent of the soft tissue dissection necessary to remove the mass. The sutures are left in place for 10 to 14 days. During this period of time the patient should limit their activities and keep the foot elevated above their heart. It is also important to keep the bandage in place and keep the surgical site dry. If the patient has been instructed to wear a removable cast or use crutches it is important that they follow the surgeons instructions. Time off from work will depend upon the level of activity required of the job and the shoes necessary for work. Generally a minimum of one week off from work is necessary. If the patient can return to work while wearing a cast and they are allowed to perform light duty then they may be able to return to work after one week.

Possible Complications

The surgery is generally successful and without complications. However, as with any surgical procedure there are potential complications. Possible complications include, infection, excessive swelling, delays in healing, tendon or nerve injury. Because the mass is a growth from a tendon, removal of the mass may require the excision of a portion of healthy tendon. This can weaken the tendon or cause scaring of the tendon. Additionally there may be small skin nerves in the area of the tumor that may have to be sacrificed when removing the mass. If this occurs there may be small areas of patchy numbness on the skin following the procedure. This is generally not a significant problem. On occasion a nerve may get bound down in scar tissue and cause pain following the surgery. Recurrence of the mass is also possible but generally not considered a complication of the procedure.

Sesamoids are bones embedded in a tendon and are recognized as two pea-shaped bones located in the ball of the foot, beneath the big toe joint.  Injuries to the sesamoids can involve the bones, tendons and/or surrounding tissue of the joint.  They are often caused by individuals participating in physical activities that require increased pressure on the ball of the foot, such as running, basketball, football, golf, tennis and ballet.  Individuals with high arches are at risk for developing sesamoids as well as frequent high-heeled shoe wearers.  There are three types of sesamoid injuries that can occur in the foot: turf toe, fracture and sesamoiditis.  Turf toe is an injury to the soft tissue surrounding the big toe joint and usually occurs when the big toe is extended beyond its normal range.  Symptoms include immediate, sharp pain and swelling.  Sometimes a pop is felt at the moment of injury.  Fracture is a sesamoid bone can be acute or chronic.  An acute fracture is caused by trauma, produces immediate pain and swelling, but does not affect the entire big toe joint.  A chronic fracture is a stress fracture that produces longstanding pain in the ball of the foot behind the big toe joint and is aggravated with activity and relieved with rest.  Sesamoiditis is an overuse injury involving chronic inflammation of the sesamoid bones and the tendons involved with those bones.  It's caused by increased pressure to the sesamoids and often produces a dull, longstanding pain beneath the big toe joint.  Treatment of sesamoids vary, but can include: padding, strapping or taping, steroid injections, orthotics, oral medications, physical therapy or immobilization.  In some cases, surgery may be recommended.    

A subungual exostosis is a bony prominence that can occur under the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. When they are symptomatic, removal of the spur is the treatment of choice. Additionally other small tumors called osteochondromas and enchondroma can also form in the bone beneath the toenail as well as in other bones in the body.

An osteochondroma is a benign bone tumor that accounts for 50% of all benign bone tumors. They have a predilection for the long tubular bones of adolescents and young adults. Its peak incidence is in the second decade of life with a male to female ratio of approximately 2:1. They are generally painless or minimally painful unless they cause irritation to the surrounding tissue. When they are in the bone beneath the toenail they can deform the toenail and cause an ingrown toenail. The treatment of symptomatic osteochondromas is surgical excision. The final diagnosis is made after the bone tumor is removed and examined by a pathologist. Recurrence of the tumor is possible following their removal. Hereditary multiple exostosis (osteochondromatosis) have a prominent hereditary incidence which affects males more often then females. The disease is characterized by the presence of multiple exostosis, which are frequently bilateral and somewhat symmetrical and usually make their appearance during childhood or adolescence.

Enchondroma is a fairly common benign cartilaginous tumor, which is the most common bone tumor of the hands and feet. They affect patients in a wide age range with no sex predilection. When they occur within the small tubular bones the tumor can involve large portions of these bones, causing thinning of the cortex of the bone. This can weaken the bone and cause it to break spontaneously. When they occur in the small bone in the end of the toe they can cause pain that may mimic the pain of ingrown toenails. Ollier's disease, also known as enchondromatosis, shows a strong predilection for the small bones in the hands and toes (phalanges) and the long bones behind the phalanges called metatarsals. It is often shows an asymmetric involvement, tending to affect one side of the body more than the other and has a propensity to transform into a malignant sarcoma. Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas.This tumor has a greater predilection for the hands and feet, and has a greater tendency toward malignant transformation than Ollier's disease.

Deformities of the toes are common in the pediatric population. Generally they are congenital in nature with both or one of the parents having the same or similar condition. Many of these deformities are present at birth and can become worse with time. Rarely do children outgrow these deformities although rare instances of spontaneous resolution of some deformities have been reported.

Malformation of the toes in infancy and early childhood are rarely symptomatic. The complaints of parents are more cosmetic in nature. However, as the child matures these deformities progress from a flexible deformity to a rigid deformity and become progressively symptomatic. Many of these deformities are unresponsive to conservative treatment. Common digital deformities are underlapping toes, overlapping toes, flexed or contracted toes and mallet toes. Quite often a prolonged course of digital splitting and exercises may be recommended but generally with minimal gain. As the deformity becomes more rigid surgery will most likely be required if correction of the deformity is the goal.

Underlapping Toes

Description

Underlapping toes are commonly seen in the adult and pediatric population. The toes most often involved are the fourth and fifth toes. A special form of underlaping toes is calledclinodactyly or congenital curly toes. Clinodactyly is fairly common and follows a familial pattern. One or more toes may be involved with toes three, four, and five of both feet being most commonly affected.

The exact cause of the deformity is unclear. A possible etiology is an imbalance in muscle strength of the small muscles of the foot. This is aggravated by a subtle abnormality in the orientation on the joints in the foot just below the ankle joint called the subtalar joint. This results in an abnormal pull of the ligaments in the toes causing them to curl. With weight bearing the deformity is increased and a folding or curling of the toes results in the formation of callus on the outside margin of the end of the toe. Tight fitting shoes can aggravate the condition.

Treatment

The age of the patient, degree of the deformity and symptoms determine treatment. If symptoms are minimal, a wait and see approach is often the best bet. When treatment is indicated the degree of deformity determines the level of correction. When the deformity is flexible in nature a simple release of the tendon in the bottom of the toe will allow for straightening of the toe. If the deformity is rigid in nature then removal of a small portion of the bone in the toe may be necessary. Both of these procedures are common in the adult patient for the correction of hammertoe deformity. If skin contracture is present a derotational skin plasy may be required.

Overlapping Toes - Overlapping Fifth Toe

Description

This deformity is characterized by one toe lying on top of an adjacent toe. The most common toe involved is the fifth toe. When one of the central toes is involved the second toe is most commonly affected. The etiology of the condition is not well understood. It is though that it may be caused by the position of the fetus in the womb during development. The condition my run in families so there may be a hereditary component to the deformity.

Treatment

Effective conservative treatment depends upon how early the diagnosis is made. In infancy, passive stretching and adhesive tapping is most commonly used. This may require 6 to 12 weeks to accomplish and reoccurrence is not uncommon. Rarely will the deformity correct itself. As the individual matures the deformity becomes fixed. When surgical correction is warranted a skin plasty is required to release the contracture of the skin associated with the deformity. Additionally a tendon release and a release of the soft tissues about the joint at the base of the fifth toe may be required. In severe cases the toe may require the placement of a pin to hold the toe in a straightened position. The pin, which exits the tip of the toe, may be left in place for up to three weeks. During this period of time the patient must curtail their activities significantly and wear either a post-operative type shoe or a removable cast. Excessive movement at the surgical site can result in a less than desirable result. The pin can be easily removed in the doctor's office with minimal discomfort. Following removal of the pin splinting of the toe may be required for an additional two to three weeks.

Hammertoes and Mallet Toes

Description

Another common digital deformity is contracture of the toes in the formation of hammertoes and mallet toes. Hammertoes are described in depth in another article. Mallet toes are a result of contracture of the last joint in the toe. In the pediatric population it is often flexible and not painful. Over time the deformity becomes rigid and a callus may form on the skin overlying the joint at the end of the toe. Additionally the toenail may become thickened and deformed form the repetitive jamming of the toe while walking. The deformity usually involves one or two toes, with the second toe most commonly affected. Mallet toes have several etiologies. Longer toes that are forced against a short toe box in the shoe will, over time, develop a contracture of the last joint in the toe causing a mallet toe.

Treatment

Conservative treatment consists of padding and strapping the toes into a corrected position. This treatment may alleviate the symptoms but will not correct the deformity. Diabetic patients often develop ulcerations on the ends of their toes secondary to mallet toe deformity and the pressure that results from the toe jamming into the shoe. When standing, the toe will demonstrate a contracture, with the tip of the toe facing downward into the floor. If the deformity is flexible a simple release of the tendon in the bottom of the toe will allow straightening of the toe. Following the procedure the patient must avoid shoes that cause jamming of the toe or the deformity can reoccur. When the deformity is rigid surgical correction requires the removal of a small section of bone in the last joint of the toe. On occasion fusion of the last two bones in the toe may be necessary. This requires removing the cartilage from the last joint in the toe and pinning the bones together. When the bone heals it forms a single bone and the toe remains in a straightened position. Healing time is dependent upon the procedure selected. If a tendon release is performed the patient my return to a roomy shoe within a week. If the toe is straightened by removing a section of the bone in the toe it make ten days to three weeks for a patient to return to normal shoes. If a fusion is performed to straighten the toe, the patient may not return to normal shoes for 6 to 8 weeks. Time off from work will depend upon the type of shoe gear that must be worn and the level of activity necessary to perform the job. A minimum of three to four days off from work is generally recommended and longer if the job responsibilities can not be modified to accommodate the normal healing time for the surgery.

The big toe, called the Hallux, is made up of two small bones called phalanges. This condition presents as a cocking up of the big toe at the joint between these two small bones. In the early stages of the condition the deformity is flexible, in later stages the deformity becomes rigid. It is caused by a variety conditions. Neurological diseases that cause muscle weakness or muscle imbalance in the muscles of the lower leg can result in the formation of Hallux hammertoe. This is commonly seen in patients after they have suffered a stroke or Cerebral Vascular Accident. Damage to certain areas of the brain during a stroke will frequently result in weakness and/or paralysis on one side of the body. If the stroke is not severe the patient may recover a majority of the function of the muscles in the legs and feet. However a residual result may be a cocking up of the big toe.

Other causes of the condition include damage or laceration to the tendon on the bottom of the big toe. Surgery to correct bunion deformities, in rare cases, may result in an imbalance of the structures about the big toe joint and cause the condition. An additional cause of hallux hammertoe is the absence of two small bones, called sesamoid bones, which are normally present beneath the big toe joint. There is an uncommon condition where a person may be born without these bones. More commonly however, the absence of one or both of the sesamoid bones is due to their surgical removal. In the course of correcting a bunion deformity one of the sesamoid bones may be removed. In another situation, a fracture of one or both of the sesamoid bones may result in the necessity to remove them to cure the pain associated with the injury (See the description of sesamoditis).

A high arched foot may also result in the formation of, not only a hallux hammertoe, but also hammertoes of all of the toes.

A consequence of having a hallux hammertoe is irritation on the top of the toe from shoe pressure or the development of a painful callus on the end of the big toe. People who have had a stroke or who have diabetes with peripheral neuropathy may not have pain associated with the callus on the end of the toe. These areas may ulcerate and become infected.

Diagnosis

The diagnosis of hallux hammertoe is made by clinical exam. An x-ray is useful in determining the degree of the deformity and the condition of the joint. The presence or absence of the sesamoid bones is also made using an x-ray. If a neurological condition has not been identified and there is absence of trauma or previous surgery in the area, then evaluation by a neurologist may be appropriate.

Treatment

The need for treatment is based upon the level of symptoms the patient may be experiencing. Splitting the toe in an attempt to straighten it is of little value and is certain to fail. If treatment is needed, surgical correction of the deformity has the greatest level of success.

If the deformity is flexible a simple tendon release procedure can be performed. This consists of making a small incision on the side of the toe and cutting the tendon in the bottom of the toe. If an ulceration or open sore is present on the end of the toe cutting the tendon to relax the toe may be all that is necessary to allow the ulceration to heal. This procedure can easily be performed in the doctor's office under a local anesthesia. Following the surgery a dressing is applied to splint the toe in a straighten position. The sutures and the bandage are kept in place for 7 to 10 days. The patient should keep their activities to a minimum during this period of time and keep the area dry. A post-operative type of shoe is worn to accommodate the bandage. Generally a patient can return to normal shoes within two weeks and resume complete normal activities in three weeks.

If the deformity is rigid then fusion of the joint will be necessary to correct the deformity. Under certain circumstances the foot surgeon may elect to fuse the toe when the deformity is flexible. Fusion of the toe requires removing bone at the level of the joint in the toe. The articular surfaces of the joint are removed and the two small bones are abutted up against one another and held in place by a small screw. This fuses the two pieces of bone together resulting in permeate straightening of the toe. This procedure is generally performed in an out-patient surgery center or hospital. The surgery can be performed under a local anesthesia but the patient and surgeon may prefer to use a twilight anesthesia for the patient's comfort. Following the surgery a fluff dressing is applied. The sutures will remain in place for 7 to 10 days. During this period of time the patient should significantly reduce their activities and keep their foot elevated. It takes 6 weeks or longer for the bones to fuse. During this period of time the patient should wear a stiffed-soled post-operative type of shoe. Bending of the toe will delay or inhibit the fusion of the bones. Quite often it takes three months before the patient can return to full-unrestricted activity.

Possible Complications

Possible complications include infection, excessive swelling, and delays in healing or failure of the bones to fuse. Overall the procedure has a very high success rate. On occasion, over time, the screw may begin the cause irritation on the tip of the toe and have to be removed.

Stiffness of the big toe joint is termed Hallux Limitus. Hallux is the medical term for the big toe. When the big toe possesses no motion, it is termed Hallux Rigidus. To confuse the topic, the big toe joint may appear to have normal motion, but this motion can be limited when weight is on the foot and during the normal standing and walking. This is termed functional Hallux limitus, because it occurs during the normal functioning of the foot while walking. As with many conditions that affect the foot, functional conditions progress to structural deformities. As the condition progresses, a degenerative type of arthritis develops in the big toe joint.

Diagnosis

The most common cause of Hallux limitus is an abnormal alignment of the long bone behind the big toe joint called the first metatarsal bone. In this condition, the first metatarsal bone is elevated relative to the other metatarsal bones that lie behind the other toes. When this is the case, the big toe joint cannot move smoothly and jamming occurs at the joint. A variety of symptoms can begin to occur. One common problem that occurs is pain in the bottom of the big toe where a central callus can develop. The pain and callus develop because the big toe does not bend upward enough as the bottom of the toe is jammed into the ground. People who have diabetes must watch this area carefully because the pressure can cause the development of an ulceration that can become infected.

Another consequence of the jamming of the big toe joint is the development of bone spurs on the top of the joint. This bump on the top of the big toe joint can become painful as a result of shoe pressure. Pain within the joint is a common result of the limitation of movement of the big toe joint. With time, the big toe joint becomes stiff and painful to move. As the joint continues to degenerate more bone spurring occurs. If the condition is left untreated complete destruction of the joint can occur.

Diagnosis is made by performing a physical exam of the foot and the use of x-rays. In early stages of the condition x-rays may be normal. In later stages of the condition, narrowing of the joint and/or bone spurs may be evident.

Treatment

Initial treatment consists of using oral anti-inflammatory medications, cortisone injections and/or functional orthotics. Oral medications and cortisone injections are useful in treating the pain associated with the condition, but will not stop the process because they do not address the underlying cause of the condition. Functional orthotics, however, are designed to treat the cause of the condition. These devices will generally fit into normal shoes and correct the underlying functional problem with the joint. Orthotics will not reverse what damage may have occurred, but can slow or halt the on-going damage to the joint.

If the condition progresses to the point of spurring around the joint, surgery may be indicated. Depending upon the degree of degeneration of the joint, surgery may consist of simply removing the bone spurs around the joint, a decompresion osteotomy or may require a total joint replacement or joint fusion. Following surgery, the use of a functional orthotic is useful to improve the joint function.

If a painful callous exits on the bottom of the big toe it will frequently resolve and the pain subside with the use of functional orthotics and/or surgery to improve the motion of the joint.