“DON’T GO for the knee replacement until you are really suffering,” advised my orthopedist, “Otherwise you won’t be happy with the new knee.”
What I understood from his words was that, more than most medical decisions, this one is based on subjective criteria and mine alone to make. (The knee cartilage wore away years ago following arthroscopy and a meniscus repair, but mostly from arthritis and years of use.)
For problems with the body’s skeleton, including bones, joints, tendons and muscles, individual variations in body as well as mind—personal responses to pain and disability—make it difficult to generalize about which specialties and which treatments are most helpful, but the interventions are irreversible and not to be undertaken lightly.
For many people, one skeletal problem area that can be the root of much bigger ones along the way but is often ignored, overlooked or forgotten is the big toe. Its dysfunction is capable of throwing off and sometimes requiring replacement of the bigger joints, upwards from toe to head: ankles, knees, hips and even shoulders. “Unlike their parents, Baby Boomers do not accept foot pain as a natural part of aging,” according to Boston foot and ankle surgeon John Giurini. Even so, many boomers find themselves facing knee or hip replacement —or at least foot surgery—because of difficulties that began in the big toe years before.
Also, the same advances in medical technology that offer relief from big-toe problems—also used for hips and knees—can create unduly “high expectations, sometimes too high,” according to Cleveland foot and ankle surgeon Stephen Frania.
With each step forward, the big toe supports 50% of the body’s weight, making the MPJ or metatarsophalangeal joint the most likely target for osteoarthritis or posttraumatic arthritis and leading to hallux rigidus —loss of movement— or “stiff big toe.” (Hallux limitus is decreased movement.)
Hereditary or congenital defects in the foot or faulty foot mechanics can trigger arthritis, as can certain athletic activities—for example, “turf toe” in athletes who play games on artificial surfaces, which is caused by the sudden bending back of the big toe. Some studies suggest women are more likely to develop hallux rigidus.
Of the two most common traditional big toe interventions, cheilectomy involves removing damaged cartilage along with spurs or overgrowths and allows for immediate weight-bearing after the procedure. By contrast, surgical fusion or arthrodesis can require weeks or months off the foot to give the two joint bones that have been fixed in place time to heal together. Fusion also removes remaining motion from the MPJ.
The newest intervention involves synthetic implants, such as Cartiva, which is made of the same material used in contact lenses and designed to mimic natural cartilage found in the joint. Implants create space between the bones and allow for more movement than the other alternatives. Used in the U.S. since 2016, implants offer the possibility of weight-bearing on the joint as soon after surgery as tolerable, often the next day.
Cartiva has also proved helpful for knees. In a study of long-term benefits, 18 patients, average age 54, reported improvement five to eight years after surgery. On the other hand, there are so many options for failing knees, including constantly emerging new options for knee replacements like the “Chicago knee,” that deciding on an intervention becomes almost impossible.
For shoulder pain, reflection on the complications crystallizes in this first sentence of the Mayo Clinic report: “Shoulder pain may arise from the shoulder joint itself or from any of the many surrounding muscles, ligaments or tendons.” While specialists often recommend MRIs of knees and shoulders to check for tears, questions remain about the best approach even in that instance, with surgery not always a good choice.
Before big-toe surgery, Brigham and Women’s chief podiatrist James P. Loli, writing on a Harvard Health blog, recommends a first step of investing in properly fitted shoes —noting that foot length and width change with age, and many people fail to have their feet properly measured “for years.”
After shoes come orthotics, with three options: over-the-counter, “kiosk-generated” and professional custom orthotics. For a person “of average weight, height and foot type and with a generic problem such as heel pain,” OTC or kiosk can work fine —though they made need more frequent replacement, according to Loli.
Specific problems that may do better with prescription orthotics—more expensive and usually not covered by insurance—include severe flat feet as well as poor circulation and neuropathy (loss of feeling). Neuropathy—suffered most severely by those with diabetes — can be idiopathic, with no known cause, or follow traumatic injury, exposure to toxins, or infection—in my case, Lyme disease.
Visiting a podiatrist for a toe blister that worsened unnoticed because of neuropathy brought up questions for me similar to those seeking help for an aching big toe—and many other orthopedic issues —such as how bad is the discomfort, and it’s just a toe. At what point is it time for a medical intervention and how to choose the best one?
When I confided my worries that I had waited too long with the blister, the podiatrist told me, “The woman who came in yesterday, she’ll probably lose her leg!” But when I expressed sympathy for the woman, a diabetic, who made my neuropathy seem insignificant, the podiatrist assured me: “Neuropathy is neuropathy. But you won’t lose the toe.”
Mary Carpenter regularly reports on topical issues in health and medicine.