Can Orthotics Relieve Pain After A First Metatarsal Fusion For Hallux Rigidus?

A reader recently contacted me regarding pain following first metatarsal fusion due to hallux rigidus. Once the patient started trying to walk postoperatively, there was significant pain underneath the “last joint of the big toe” but no pain at the metatarsophalangeal joint (MPJ). The patient has tried to determine the cause of the pain with no success for the last 18 months with the original surgeon saying the fusion is okay. 

A second surgeon told the patient either the angle of the toe was fused too low or the hardware was to blame. Removing the hardware did not solve the problem. This is not uncommon but it is a pesky complication when the big toe is not fused high enough so the end of the toe becomes the low point when pushing off and holds all the patient’s body weight.

A physical therapist believes pronation of the patient’s left ankle might be a cause of the pain. The patient notes always having some ankle pronation but never having pain under the toe until the fusion. 

For patients like this, one may employ orthotics to distribute deforming forces. The physical therapist suggests a medial wedge but a medial wedge will cause problems due to more constant supination. Typically, it is a balancing act of providing some lateral support so as not to supinate at all and offering some off-weightbearing padding on a full-length orthotic device to take pressure away from the point of pressure. 

This patient needs stability with the weight spread out on the big toe, just not on the sore spot. After a fusion, the benefit is to have a stable big toe joint that is not painful and can accept all this weight at least in theory. Accordingly, this patient needs a stable orthotic that loads 90 percent of the big toe as opposed to offloading the big toe. 

Editor’s note: This blog originally appeared at https://www.drblakeshealingsole.com/2018/12/problems-post-big-toe-joint-fusion.html . It is reprinted with permission from the author.