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When A Patient Has First MPJ Pain After Immobilization: Is Surgery Necessary?

I recently received an online inquiry from an individual who recently suffered a Jones fracture and subsequently had surgery with open reduction and internal fixation with a titanium screw in early July. Preoperative X-rays did show mild arthritis in the great toe, and she did admit to some related discomfort prior to the fracture, but no difficulty in weightbearing. 

According to the patient, X-rays from September 2020 show good progress in healing of the fifth metatarsal fracture but significant arthritis in the great toe joint. This is perplexing to her and this is what prompted the inquiry to me. 

The treating podiatrist quickly recommended a first MPJ fusion but the patient does not want to proceed with surgery as she feels the recent fracture surgery and non-weightbearing recovery were traumatic for her The patient is currently in physical therapy and says there is still some movement in the toe. However, she says the joint is painful when pushing through for walking. Hoka® One One shoes and custom orthotics are part of the current plan.

This patient wonders why the toe arthritis may have worsened so much while she was in a cast boot. I disagree with the treating podiatrist. This person does not need a first MPJ fusion, at least not right now, and hopefully not for a long time.

For whatever reason, immobilization (in this case due to the fracture and subsequent surgery) causes joints to freeze up. We know that motion is good for lubricating arthritic joints but excessive motion can be problematic. I am curious to see how this patient will feel in three months or so. For now, the Hokas with the rocker sole sound great. At this stage, the orthotic may or may not be helpful, but if not, it may be helpful later. I’d encourage the patient to learn more about dancer’s padding to offload the great toe joint and experimenting with spica taping to limit the motion during an activity that would cause pain. 

Additionally, I would caution for physical therapists to not try to increase the range of motion as I have found it can backfire when there is arthritis in the great toe joint. The goal is to reduce pain, not increase range of motion in physical therapy. It is best to let normal pain-free walking slowly stretch out the joint. I advise patients in these situations to ice three times a day for 10 to 15 minutes to cool off the joint. However, a physical therapist can use iontophoresis to calm the joint down as well.

Again, non-weightbearing does not help in cases of arthritis in the big toe joint. I advocate for gradually finding the amount of day-to-day walking that is tolerable. This is where the shoes, orthotics, dancer’s padding and spica taping come into play. If the pain is still not tolerable, I would rather have this patient be back in a walking boot for two months (with the emphasis on walking) than not walking at all. 

Overall, immobilization may heal a primary issue but secondary issues can crop up. In my experience, surgery is many times not the immediate best answer. The pain this patient has in the great toe joint is acute. She has not undergone conservative treatment. Even if the patient needs surgery, I feel a minimum of six months of conservative therapy is necessary first in these cases. Instead, I focus on a sustainable pathway, if possible, to keeping the patient active and pain-free.

Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine. Dr. Blake is the author of the recently published book, “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet,” which is available at www.bookbaby.com

Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.

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