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a medical mystery?

Posted by Karen L. on 12/02/04 at 10:53 (165082)

Hi, I asked about my big toe pain a while back and Dr. Z said that it could be a bone spur on the big toe. Well, i went to my orthopedic doc and he did an x-ray and said no spur and that he did not know what is causing the pain in my big toes. I am so miserable because this has been going on for 2 years now and the pain is killing me, every pair of shoes I try on make my toes hurt.When this started 2 years ago i had been diagnosed with tts, by having nct and emg (about 5 months prior to this toe pain in my nail beds)so the doctor told me it was tarsal tunnel and that i needed surgery. The pain seemed to subside when i wore my custom orthotics, but they caused knee pain so i couldn't wear them. Since then i have tried over the counter orthotics and they seem to cause more pain. For a while the pain subsided with wearing 1 certain pair of shoes and a 3/4 arch support but now the shoes are old and worn and the pain is back with a vengence!Just recently I was ready for tarsal tunnel surgery and my doc wanted me to repeat the nct and emg tests before surgery and these tests were normal-to my dismay! So now I'm wondering what is causing this bad pain in my toes, the doctor is researching problems with toe nails and I'm going to see him in 2 weeks! This is just great- I cry a lot and I am very depressed, does anyone have any suggestions? I would appreciate it.

Re: a medical mystery?

Ed Davis, DPM on 12/02/04 at 19:38 (165101)

Karen:
If you try to bend the big toe joints backward (bringing the big toe up), how many degrees, just approximately would you say you could do so starting with the level of the floor as the zero degree point?
Ed

Re: a medical mystery?

Karen L. on 12/03/04 at 07:21 (165118)

Dr. Davis, Neither of my toes will bend back to far,I have hallicus limitus. Is that what your asking? I am going to say about 15-20 degrees.

Re: a medical mystery?

Ed Davis, DPM on 12/03/04 at 10:37 (165126)

Karen:
You have given us the diagnosis: hallux limitus or halux rigidus; a very common and curable condition. You really need to see someone with experience and expertise in treating that. Where do you live as I might know someone in your area? Also a good resource for a doctor finder is http://www.acfas.org
Ed

Re: a medical mystery?

Karen L. on 12/04/04 at 10:05 (165180)

Dr. Davis, I live in Md., I was wondering if the hallicus limitus can cause pain in the top of the big toes, near the nail beds? I've always thought that the pain was being caused by my biomechanics, is that why you asked about pulling my toes back? I really appreciate you answering me, as this pain is really affecting my quality of life. Karen

Re: a medical mystery?

Ed Davis, DPM on 12/04/04 at 15:35 (165185)

Karen:
In order to be able to push off on the big toe joint properly one needs about 65 degrees of dorsiflexion (bend back) motion of the big toe joint.
If the motion does not exist several things can happen:
1)pain can develop either at the top, bottom or within the big toe joint.
2)the big toe may compensate by abnormal upward bending at the small joint behind the nail causing that joint to hurt and the area around the nail can hurt due to the pressure being placed there due to lack of motion at the first MTP joint (the big toe joint).
3)one may compensate by using the lessor toe joints to push off making the balls of the feet sore.
4)one may compensate by walking on the outside of the feet, making it easier to turn the ankle and causing hip pain.

Hallux limitus is divided into 4 stages depending on the range of motion lost and degree of caritlage worn away. The stage one is in determines the treatment. Getting this part right is crucial since the right procedure is more important than the technique used instead.

The only realistic conservative treatment is to have an orthopedic shoe store or pedorthist place a distal rocker sole on your shoe(s). What that accomplishes is to allow you not to bend the big toe joint while having the shoe rock forward, that is, the shoe modification does the work of the big toe joint.

From a surgical point of view:
Late stage 1 to stage 2: Cheilectomy - removal of excess bone on the top of the toe and first metatarsal head (knuckle) to restore lost motion.
Late stage 3 to early stage 3: cheilectomy plus a repositioning of the cartilage of the first metatarsal head downward. Mid to late stage 3: the aformentioned procedures plus a hemi (half) big toe joint implant. Stage 4: fusion of the big toe joint or total implant arthroplasty (preferred).
The best total implant on the market, in my opinion is the Futura Biomedical Generation 2 hinged implant -- see http://www.futurabiomedical.com

If considering surgery, it is crucial that the doctor you see understands the stages and have a good working knowledge of big toe joint implants.
Ed

Re: a medical mystery?

Ed Davis, DPM on 12/04/04 at 15:39 (165186)

Correction:
Above should state: late stage 2 to early stage 3: cheilectomy plus repositioning...
Ed

Re: a medical mystery?

Karen L. on 12/06/04 at 09:14 (165256)

Thank you Dr. Davis, I will ask the new doctor i found on the web sight you gave me about this and I will let you know what happens.

Re: a medical mystery?

stephanie on 12/06/04 at 21:08 (165285)

Tarsal Tunnel, me too. I have had heal pains for 4 years. I was diagnosed with PF in Dec 2000 and tried all conservative treatments prior to surgery on both feet in Nov 2001. I still have pains after bring on my feet an hour or 2 max. I went to many doctors, tried many meds, therapies, test and nothing showed signs of TTS. Just recently discovered I have Tarsal Tunnel by a doctor in Northern VA. He is recommending surgery. After 1 hour on my feet I have pain and must get off my feet for several hours and rest till I can walk about another hour or so. I do not have pain in my toes. Let me know how your next visit goes and what the next step will be for you. Feel free to email me at (email removed).
Herndon, va