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#11 Case of the Week

Mr F is a delightful 62 year old gentleman referred to Dr Touzell by his General Practitioner for forefoot pain and difficulty weight bearing. He is a very active gentleman and was planning on walking the Camino de Santiago (prior to the coronavirus pandemic), a distance of approximately 800km. His main concern was pain on weight bearing. He described significant stiffness in his great toes which did not bother him, but  felt his foot stiffness limited the distance he was able to walk comfortably. In addition, he was starting to develop night pain on days he was particularly active. He had seen a podiatrist who prescribed a semi-rigid custom orthotic with no forefoot extension, which unfortunately did not help his pain. This is on a background of Li-Fraumeni syndrome, a rare autosomal dominant mutation of the p53 tumour suppressor gene resulting in a life-lol increase in risk of cancer. Mr F had previously been treated for a sarcoma in his right thigh, a malignant fibrous histiocytoma in his left leg as well as prostate cancer.  Despite his condition, Mr F was extremely fit and well and was frustrated that his foot pain limited his mobility and walking tolerance. On examination, he had well healed scars from his previous free flap to treat his sarcoma and malignant fibrous histiocytoma. He had bilateral dorsal bunions consistent with osteophytes from osteoarthritis at the first metatarsophalangeal joints. He was tender to palpation over the first metatarsophalangeal joints, and could only achieve five degrees of dorsiflexion bilaterally. He was tender to extremes of movement. He had not had any x-rays as he was concerned about radiation exposure given his Li-Fraumeni syndrome and wanted to limit ionising radiation as much as possible. However, clinically he presented as stage 3 or stage 4 hallux rigidus and x-ray confirmation was not required. Under normal circumstances, plain weight bearing x-rays of the foot/feet is the investigation of choice for the radiological diagnosis arthritis of the first metatarsophalangeal joint. The possibility of an MRI scan to confirm the diagnosis of stage 3 or stage 4 hallux rigidus was discussed. However, as he had not exhausted non-operative management options it was decided that further investigations would not change management at this stage so further imaging was not required. Further non-operative options were discussed with Mr F. He had not trialled a rocker-bottom soled shoe such as a Hoka runner, nor a carbon fibre plate, so he was referred to Podiatry to discuss some shoewear options and an orthotic that would offload his arthritic first metatarsophalangeal joint.  One year after trialling different runners with a carbon fibre plate, his pain has improved dramatically. He is able to walk an unlimited distance although has some stiffness in his great toes for the first 1km of his walking before the pain goes away. He no longer has any night pain. He is still aware surgery may be required in the future but is happy with his non-operative treatment of change in footwear and simple orthotic for now. Usually made by Podiatrists, carbon fibre plates are a cost-effective method of treating hallux rigidus. Podiatrist Dr Shannon Munteanu PhD has recently performed the largest randomised controlled trial to date demonstrating the effectiveness of a carbon fibre plate compared to sham shoe inserts. The abstract demonstrating preliminary results is available here.

Key learning points:

Carbon fibre plates and rocker-bottom or stiff-soled shoes are a cost-effective method of treating hallux rigidus.

Hallux rigidus can successfully be treated non-operatively and surgery should be saved for if non-operative measures are not successful. 

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