by Brandon Nelson, DPM brandon.d.nelson@live.com

by Timothy W. H. Young, DPM timwhyoung@hotmail.com

by Timothy W. H. Young, DPM timwhyoung@hotmail.com

What is Hallux Rigidus?

Hallux Rigidus is a disorder of the joint located at the base of the big toe. It causes pain and stiffness in the joint, and with time it gets increasingly harder to bend the toe. “Hallux” refers to the big toe, while “rigidus” indicates that the toe is rigid and cannot move. Hallux rigidus is actually a form of degenerative arthritis.

This disorder can be very troubling and even disabling, since we use the big toe whenever we walk, stoopd down, climb up or even stand. Many patients confuse hallux rigidus with a bunion, which affects the same joint but they are very different conditions requiring different treatment.

Because hallux rigidus is a progressive condition, the toe’s motion decreases as time goes on. IN its earlier stage, when motion of the big toe is only somewhat limited, the condition is called “hallux limitus.” But as the problem advances, the toe’s range of motion gradually decreases until it potentially reaches the end stage of “rigidus,” in which the big toe become stiff, or what is sometimes called a “frozen joint.”

Causes

Common causes of hallux rigidus are faulty function (biomechanics) and structural abnormalities of the foot that can lead to osteoarthritis in the big toe joint. This type of arthritis – the kind that results from “wear and tear” – often develops in people who have defects that change the way their foot and big toe functions. For example, those with fallen arches or excessive pronation (rolling in) of the ankles are susceptible to developing hallux rigidus.

In some people, hallux rigidus runs in the family and is a result of inheriting a foot type that is prone to developing this condition. IN other cases, it is associated with overuse – especially among people engaged in activities or jobs that increase the stress on the big toe, such as workers who often have to stoop or squat. Hallux rigidus can also result from an injury, such as stubbing your toe. Or it may be caused by inflammatory diseases such as rheumatoid arthritis or gout. Your foot and ankle surgeon can determine the cause of your hallux rigidus and recommend best treatment.

Symptoms

• Early signs and symptoms include:
• Pain and stiffness in the big toe during use (walking, standing, bending, etc.)
• Pain and stiffness aggravated by cold, damp weather
• Difficulty with certain activities (running, squatting)
• Swelling and inflammation around the joint

As the disorder gets more serious, additional sypmtoms may develop, including:

• Pain, even during rest
• Difficulty wearing shoes because bone spurs (overgrowths) develop
• Dull pain in the hip, knee, or lower back due to changes in the way you walk
• Limping (in severe cases)

Diagnosis

The sooner this condition is diagnosed, the easier it is to treat. Therefore, the best time to see a foot and ankle surgeon is when you first notice symptoms. If you wait until bone spurs develop, your condition is likely to be more difficult to manage.

In diagnosing hallux rigidus, the surgeon will examine your feet and move the toe to determine its range of motion. X-rays help determine how much arthritis is present as well as to evaluate any bone spurs or other abnormalities that may have formed.

Nonsurgical Treatment

In many cases, early treatment may prevent or postpone the need for surgery in the future. Treatment for mild or moderate cases of hallux rigidus may include:

Shoe modifications. Shoes with large toe box put less pressure on your toes. Stiff or rocker-bottom soles may also be recommended.

Orthotic devices. Custom molded prescription orthotic devices may improve foot function.

Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.

Injection therapy. Injections of corticosteroids may reduce inflammation and pain.

Physical therapy. Ultrasound therapy or other physical therapy modalities may be undertaken to provide temporary relief.

 

When is surgery needed?

In some cases, surgery is the only way to eliminate or reduce pain. There are several types of surgery for treatment of hallux rigidus. In selecting the procedure or combination of procedures for your particular case, the foot and ankle surgeon will take into consideration the extent of your deformity based on the x-ray findings, your age, your activity level, and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.

What is a Fifth Metatarsal Fracture?

Fractures (breaks) are common in the fifth metatarsal – the long bone on the outside of the foot that connects to the little toe. Two types of fractures that often occur in the fifth metatarsal are:

• Avulsion fracture. In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. This type of fracture is the result of an injury in which the ankle rolls. Avulsion fractures are often overlooked when they occur with an ankle sprain.
• Jones fracture. Jones fractures occur in a small area of the fifth metatarsal that receives less blood and is therefore more prone to difficulties in healing. A Jones fracture can be either a stress fracture (a tiny hairline break that occurs over time) or an acute (sudden) break. Jones fractures are caused by overuse, repetitive stress, or trauma. They are less common and more difficult to treat than avulsion fractures.

Other types of fractures can occur in the fifth metatarsal. Examples include mid-shaft fractures, which usually result from trauma or twisting, and fractures of the metatarsal head and neck.

Symptoms

Avulsion and Jones fractures have the same signs and symptoms. These include:

• Pain, swelling, and tenderness on the outside of the foot
• Difficulty walking
• Bruising may occur

Diagnosis

Anyone who has symptoms of a fifth metatarsal fracture should see a foot and ankle surgeon as soon as possible for proper diagnosis and treatment. To arrive at a diagnosis, the surgeon will ask how the injury occurred or when the pain started. The foot will be examined, with the doctor gently pressing on different areas of the foot to determine where there is pain.

The surgeon will also order x-rays. Because a Jones fracture sometimes does not show up on initial x-rays, additional imaging studies may be needed.

Non-surgical Treatment

Until you are able to see a foot and ankle surgeon, the “R.I.C.E.” method of care should be performed:

• Rest: Stay off the injured foot. Walking may cause further injury.
• Ice: Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
• Compression: An elastic wrap should be used to control swelling.
• Elevation: The foot should be raised slightly above the level of your heart to reduce swelling.

The foot and ankle surgeon may use one of these non-surgical options for treatment of a fifth metatarsal fracture:

• Immobilization. Depending on the severity of the injury, the foot is kept immobile with a cast, cast boot, or stiff-soled shoe. Crutches may also be needed to avoid placing weight on the injured foot.
• Bone stimulation. A pain-free external device is used to speed the healing of some fractures. Bone stimulation, most commonly used for Jones fractures, may be used as part of the treatment or following an inadequate response to immobilization.

When is Surgery Needed?

If the injury involves a displaced bone, multiple breaks, or has failed to adequately heal, surgery may be required. The foot and ankle surgeon will determine the type of procedure that is best suited to the individual patient.

What Is Gout?

Gout is a disorder that results from the build-up of uric acid in the tissues or a joint. It most often affects the joint of the big toe.

Causes

Gout attacks are caused by deposits of crystallized uric acid in the joint. Uric acid is present in the blood and eliminated in the urine, but in people who have gout, uric acid accumulates and crystallizes in the joints. Uric acid is the result of the breakdown of purines, chemicals that are found naturally in our bodies and in food. Some people develop gout because their kidneys have difficulty eliminating normal amounts of uric acid, while others produce too much uric acid.

Gout occurs most commonly in the big toe because uric acid is sensitive to temperature changes. At cooler temperatures, uric acid turns into crystals. Since the toe is the part of the body that is farthest from the heart, it’s also the coolest part of the body – and, thus, the most likely target of gout. However, gout can affect any joint in the body.

The tendency to accumulate uric acid is often inherited. Other factors that put a person at risk for developing gout include: high blood pressure, diabetes, obesity, surgery, chemotherapy, stress, and certain medications and vitamins. For example, the body’s ability to remove uric acid can be negatively affected by taking aspirin, some diuretic medications (“water pills”), and the vitamin niacin (also called nicotinic acid). While gout is more common in men aged 40 to 60 years, it can occur in younger men as well as in women.

Consuming foods and beverages that contain high levels of purines can trigger an attack of gout. Some foods contain more purines than others and have been associated with an increase of uric acid, which leads to gout. You may be able to reduce your chances of getting a gout attack by limiting or avoiding shellfish, organ meats (kidney, liver, etc.), red wine, beer, and red meat.

Symptoms

An attack of gout can be miserable, marked by the following symptoms:

• Intense pain that comes on suddenly – often in the middle of the night or upon arising
• Signs of inflammation such as redness, swelling, and warmth over the joint.

Diagnosis

To diagnose gout, the foot and ankle surgeon will ask questions about your personal and family medical history, followed by an examination of the affected joint. Laboratory tests and x-rays are sometimes ordered to determine if the inflammation is caused by something other than gout.

Treatment

Initial treatment of an attack of gout typically includes the following:

• Medications. Prescription medications or injections are used to treat the pain, swelling, and inflammation.
• Dietary restrictions. Foods and beverages that are high in purines should be avoided, since purines are converted in the body to uric acid.
• Fluids. Drink plenty of water and other fluids each day, while also avoiding alcoholic beverages, which cause dehydration.
• Immobilize and elevate the foot. Avoid standing and walking to give your foot a rest. Also, elevate your foot (level with or slightly above the heart) to help reduce swelling.
• Cortisone injections.  Help reduce pain, swelling and inflammation.

The symptoms of gout and the inflammatory process usually resolve in three to ten days with treatment. If gout symptoms continue despite the initial treatment, or if repeated attacks occur, see your primary care physician for maintenance treatment that may involve daily medication. In cases of repeated episodes, the underlying problem must be addressed, as the build-up of uric acid over time can cause arthritic damage to the joint.