Too much bone removed

by Amanda
(United States)

In 2003 I had a bunion removed and a bone spur shaved down on the top of my foot. After the surgery, my Doctor told me that he removed to much bone and I would not have full mobility in my big toe. I cannot bend this toe at all. I had problems in later years with swelling and pain and prednisone seemed to help it. I now workout everyday and experience nerve pain and after a long workout (100 minutes uphill incline on treadmill) I have what feels like a deep bone pain. I have ice on it now and just took a meloxicam. Is there any hope of some sort of treatment or physical therapy to help with this issue so that it doesn't interfere with my fitness routine? It doesn't hurt unless I work out but I don't want to stop being fit because of foot pain. Any advice would be appreciated! I will not do the cortisone shots directly into the big toe joint that one doctor wanted to do. I just can't bring myself to do that. (Unless they knock me out first) oral steriods, would that help? It has been many years since I took any. Also, the nerve pain concerns me. Is this permanent, treatable?

Thanks,
Amanda

RESPONSE

Hi Amanda,

Unfortunately, what you are left with is what you are left with. The structure of your bunion joint is the way it is. Things like cortisone injections, oral prednisone, meloxicam, physical therapy, etc. may all give you temporary relief but you will always be troubled with your foot because of its malformation.

You had surgery eleven years ago and quite frankly I am surprised you have not had more problems than those you write about. It is important to understand that you probably had bunion surgery in the first place because you had a big bump on the side of your foot and it is safe to assume there were degenerative changes in the joint itself consistent with arthritis. This is what usually makes up a bunion.

The purpose of the surgery was to give you better alignment, more range of motion in the toe joint and resolution of the bump. Because too much bone was removed, this created limitations on just how successful the procedure could be. Your problem appears to be what we refer to as a hallux limitus meaning there is limitation of motion in the big toe joint. I would be curious to know if you had motion in the big toe joint prior to surgery.

In any event, the big toe joint fails to bend upwards when it is called upon during the gait cycle. Because it needs to bend upwards, but does not, you are getting pain.

Here is the rub. Running on a treadmill in an incline position is the worst exercise you could ever do with a hallux limitus. The incline increases the need for the toe to bend upwards even more and of course in your situation, that is not happening.

Quite frankly, if you have been using an inclined treadmill all along, I am surprised that you did not have severe pain earlier on.

So, what are you going to do?

I do not know how old you are but will assume relatively young. Further surgery, although in theory may sound like a solution is probably not the solution you may envision. More than likely it would require an implant in the joint which might make up for some of the excess bone removed and might even increase some of the motion in your big toe joint.

What typically happens in a big toe joint replacement is the pain may subside as the arthritic component is removed and replaced with the artificial joint, but many patients end up with no more motion than they had before surgery. If you continue to use an inclined treadmill, there is no guarantee that you will be any better. That does not even address the possibility that you will not be worse.

In an active individual like yourself, the life expectancy of an implant is maybe fifteen years or so, meaning that at some point in time, you might be faced with additional surgery.

The approach I would take is this.

Look for a form of exercise that does not put so much strain on the big toe joint. The first thing would be to try the treadmill without the incline and see if that reduces your pain. Along those lines, you might even consider an athletic shoe, probably a cross-trainer, that has a very stiff sole. The less the sole bends, the less stress that is placed on the big toe joint. Both these suggestions might make your pain either resolve itself or greatly reduce it making exercise more tolerable.

Taking this one step further, you might consider looking for an alternate form of exercise where you can still burn calories. A recumbent exercise bike or rowing machine may give you the workout you are looking for without putting stress on your foot.

It is quite simple, the less you strain the bunion joint, the less it will hurt; there are ways to accomplish this as I have just described. As a side note, right now it appears your foot just hurts after exercise, but keep in mind, if you keep over-stressing the joint, your foot may begin to hurt all the time.

Marc Mitnick DPM
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