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Treating A Runner With Hallux Limitus Who Does Not Want To Stop Running

A 34-year-old runner with hallux limitus contacted me after seeing two podiatrists in his area, both of whom just told him to stop running. He runs 20 to 25 miles per week and says he did a couple of 50-k trail races last year but found that the steep up and down trails in the mountains irritated his toe. The patient is okay with not running these long races if it means that running them would make the condition worse. However, he would love to be able to continue to run for many years.

Hallux limitus can be functional. In these cases, adding some arch support and dancer's padding for offloading can totally reverse hallux limitus. Hallux limitus can also be structural. In these cases, the patient should try to keep the pain level between 0–2 on the Visual Analogue Scale and experiment with offloading and arch support. Patients may also have a combination of structural and functional hallus limitus.

If this patient’s first metatarsal joints have some structural damage, he can still run as long as the pain level is 0–2. If long races increase pain, the patient should avoid them. However, if he is okay running 5 to 10 miles, it is actually better for joints to have pain-free high-level loading for cartilage nourishment.  

This patient has been running in Bondi (Hoka) shoes. However, he has found that the toe box feels too small when he runs with the orthotic inserts, as suggested by a physical therapist. The patient tried Glycerin (Brooks) and Paradigm (Altra), and although both shoes felt great, he was not sure if they are great for his condition.

For this patient, I would suggest trying the wider Hoka One One shoes, which should be great for some of his running. I would also encourage the use of a medium gel toe separator to see how holding the first metatarsal in the center of its joint makes the foot feel while running. I love the Addiction or Beast (Brooks) shoes for the varus cant off the big toe but of course, we do not want this patient to roll his ankle. That said, I would have the patient try those shoes along with a 1/8-inch dancer's pad to keep the weight in the center of the foot at push-off. The zero drop shoes are good for metatarsal pain but usually not good for hallux limitus. They put patients back on their heels more for pain reduction but for most patients, zero drop shoes make it harder to push off. Some of my patients push off hard and others hardly push off at all. 

Editor’s note: This blog originally appeared at http://www.drblakeshealingsole.com/2018/02/hallux-limitus-email-advice.html . It is reprinted with permission from the author.

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