If you recently injured your toe or if your toe has been ailing for quite some time, I can help you find the best solution. Common toe problems include fractures, arthritis & hammertoes, or soft tissue ailments such as plantar plate injuries or neuromas.
Fractures (AKA Broken Toe)
A broken toe most often can be treated conservatively with splinting and occasionally a protective shoe or boot. The deciding factor is if there is significant displacement, malalignment or extension of the fracture into the joint line.
Procedure:
- When you visit, we will obtain an x-ray.
- Afterwards, I will perform a comprehensive physical exam.
- We will then collectively decide on the best treatment course. Some occasions we may need further imaging such as a CT scan or MRI.
Forefoot Pain, Hammertoes & Arthritis/Bunion
Is it hard to find good fitting shoes since the top of the toe knuckle rubs on shoes? Or is your bunion becoming annoying and painful? The common cause of hammertoes is an imbalance between the muscles of your toes (intrinsic) and your leg (extrinsic). Surgery is not always necessary, especially if you have a flexible hammertoe.
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Forefoot Pain:
Forefoot pain is commonly called “metatarsalgia” and is thought to occur from mechanical overload (ie, a flexible first ray), long second metatarsal, tight calf muscle (ie, equinus contracture). Typical conservative care includes modified shoes & activities, orthotics, metatarsal padding, and physical therapy.
When conservative measures fail surgery can include stabilizing the flexible first ray by fusing the 1st tarsometatarsal joint, shortening long metatarsals or both.
Neuromas are a common occurrence in the foot especially given how many steps we take on an average day. Neuromas typically occur between the 3rd & 4th toes since the medial & lateral plantar nerve contribute to form the common digital nerve (ie, makes it thicker) but can occur between the other toes. Some have attributed neuromas to foot type, narrow shoes, type of activities, but regardless of the cause by and large the most common treatment for neuromas is conservative to include neuroma pads, orthotics, modified shoes and activities, and ultrasound guided steroid injections. Despite most neuromas responding to conservative care some require surgery. The most common surgical procedure for neuromas is excision.
Hammertoes:
Another common complaint in the forefoot is hammertoes. Hammertoes can either be rigid or flexible (ie, you can straighten the toe with your fingers). Flexible hammertoes tend to respond to taping, padding, wide toe box shoes and orthotics. Rigid hammertoes are challenging to treat conservatively but still an attempt of conservative care should be attempted. When the conservative measures fail surgery involves fusing the hammertoe joint (ie, proximal interphalangeal joint) and stabilizing it with a pin that is removed at around 4 weeks.
- Flexible Hammertoes — The toe can be manually changed to look straight, but when you release the toe it returns to being a hammertoe.
- Rigid Hammertoes — The toe deformity does not move, regardless of how hard you push, prod and pull.
Flexible hammertoes are treated with taping and bracing, such as the Budin splint. Rigid hammertoes can be treated with wide toe box shoes but more often are the ones that tend to need surgery if you can’t find shoes that fit without causing pain. Bunions are treated with toe spacers, orthotics, and modified shoes. There are more than 100 procedures available for bunions, and I commonly perform either the Lapidus vs. BOAT bunionectomies.
Arthritis of the Big Toe AKA Hallux Rigidus:
Hallux rigidus the medical term for arthritis of the big toe joint. It typically arises from an accumulation of “micro trauma” and tends to worsen with time and activity. Conservative treatment includes orthotics, NSAIDs (eg, ibuprofen), modified shoes & activities, steroid injections, and more. However, these tend not to stop the progression of the arthritis.
Surgical intervention depends on the degree and level of arthritis. For bone spurs with relatively little cartilage involvement can be treated with bone spur removal (AKA cheilectomy) and in addition Dr. Kim tends to also concurrently perform a Moberg osteotomy, which is removing a triangular piece of bone to gain artificial dorsiflexion. Dr. Kim performed a cadaveric study that showed removing a 3 mm wedge of bone would change the contact pressure to center on non arthritic cartilage. However, if the arthritis is severe (eg, Grade 3) the options are fusion or Cartiva implantation. Dr.Kim is a recognized provider who performs Cartiva and the midterm results have been promising.
Bunions AKA Hallux Valgus:
The etiology of bunions is multifactorial, for instance there can be an association with shoe wear and have a hereditary component, regardless of cause, the treatment of bunions should be initiated with conservative care to include modified shoes, orthotics, bunion spacers and splints. Its advisable to obtain x-rays annually to obtain objective evidence if the the bunion is worsening.
Dr.Kim counsels his patients to seek surgical intervention once bunions become painful and his patients have failed a course of conservative treatment.
Historically there are more then 100 procedures reported for bunions. Dr.Kim believes in identifying the source of the bunion and not focus on just getting rid of the bump. Typical sources include hypermobility of the tarsometatarsal joint, subluxation of sesamoids, ligamentous laxity, etc… Given this approach Dr.Kim performs three bunion procedures to include, BOAT ostetoomy, SCARF osteotomy and Lapidus bunionectomy. Often these procedures are accompanied by smaller procedures if need be, such as lateral capsular release, Akin osteotomy, BMAC, etc…
If you have received a diagnosis of arthritis of the big toe (ie, Hallux Rigidus) and would like to learn more, please call Dr. Paul Kim at 415-927-5300 for an appointment and after an evaluation an optimal treatment plan will be tailored to get you back to your active lifestyle.
Soft Tissue Ailments
When it’s not a fracture or a hammertoe/bunion, then a few other common causes of toe pain can be neuromas, plantar plate/capsule injuries or metatarsalgia. When nerves become injured or chronically agitated, they can develop into neuromas. Plantar plate/capsule injuries from trauma or degeneration can lead the development of crossover toes. Metatarsalgia is a term often used to describe forefoot pain without a distinct etiology.
Typical uses for soft tissue ailments of the toe:
- Splints (e.g., Budin Splint)
- Pads (e.g., metatarsal plants, silicone sleeves)
- Orthotics
A lot of toe ailments respond to conservative care such as orthotics (i.e., shoe inserts), special pads and taping and even physical therapy. Only after a trial of conservative care has been tried and failed should we discuss surgery.
Bunions can become painful when the nerve that is “draped” by the bunion becomes irritated. Surgery is not the first line of treatment for bunions; instead it is orthotics, spacers, and splints with a good pair of shoes. When these measures fail, then surgery can be explored. There are more than 100 surgical procedures for bunions. They are classified as distal, shaft and proximal procedures. Before deciding on the procedure, the nature of the foot with a detailed musculoskeletal exam in line with patient goals have to be taken into account.
Arthritis can develop in bunions but more often arises from “microtrauma” to the big toe. When arthritis sets in its called “hallux rigidus” and depending on the severity of arthritis can be treated conservatively with orthotics and injections, but if these fail then surgical intervention should be explored.
Toe Surgeon in San Francisco, CA
Thank you for your interest in my specialty. If you have any questions please feel free to call my office or send me a message using the contact form on this page. I will get back to you as soon as possible. I have clinic locations in San Francisco and Larkspur and serve patients throughout the Bay Area.
