Caring Medical - Where the world comes for ProlotherapyProlotherapy for Bunions | Metatarsophalangeal Joint Pain

Ross Hauser, MD

We see many patients at our clinics with various problems of the feet. One problem is a problem of a bunion. A bunion is a bony enlargement of the joint at the base of the big toe (the metatarsophalangeal or MTP joint).

How did it get there? All joints in the body, when they become unstable or weak, will form bone spurs or bony over growths to prevent the joint from hyper-extending and causing more damage to itself.

A joint also forms this bony overgrowth to continue to be able to function as best it can in your body’s musculoskeletal community. In other words, the bony overgrowth helps the joint function enough so that the other joints do not have to assume over compensatory roles to keep balance in the body. Unfortunately over time the bone spur itself becomes the problem as it continues to grow and impede function. It is at this time joint replacement or fusion surgery is considered.

Let’s focus on the big toe. Your big toe formed this bone not only to protect itself, but also to provide support to the rest of the foot. If the big toe is not functioning, it can cause problems throughout the foot as the rest of the structure tries to overcompensate, the big toe is trying not to be a burden.

If the big toe becomes a problem, it can cause gait abnormalities that can lead to ankle pain, Achilles tendon problems, plantar fasciitis, knee pain, hip pain and lower back pain. The big toe has a big job to do in keeping balance among the foot and joints.

You have to do something with your bunion because it is more than a problem of your toe.

valgus deformity toe

A bunion is also referred to as hallux valgus in the medical community. The name describes the problems of your big toe “hallux’, with a “valgus” a deformity which is pushing the toe away from the foot at the joint

A bunion is also referred to as hallux valgus in the medical community. The Latin name describes the problems of your big toe “hallux’, with a “valgus” a deformity which is pushing the toe away from the foot at the joint. See the x-ray to the left.

The surgery – non-surgery discussion

If you are reading this article it is very likely that you have graduated out of “conservative care options,” and need to explore something more aggressive for your toe problems. Perhaps surgery.

For most patients a bunion does not have to be treated surgically. It can be “managed” with conservative care. In this article we will explain the difference between managed bunion care and regenerative medicine injections which can halt the progress of the bunion.

Realistic expectation of what conservative care can do for a bunion

This is what a team of hospital clinical researchers in Japan wrote in the Journal of orthopaedic science🙁1)

“Nonoperative treatment using foot orthoses (shoe inserts or other types of brace or splint) decreased pain in patients with hallux valgus. The effect of treatment was maintained up to 2 years with a relatively high degree of patient satisfaction. However, treating physicians should inform patients to set realistic expectations and be aware that a limited degree of pain reduction is expected.”

Here we should not that at two years of wearing inserts and other appliances, the bunion pain was managed, but limited.

The surgical option

In December 2016, doctors in the Czech republic published troubling finding on bunion surgery in the medical journal Clinical Biomechanics.

  • The aim of the study was to compare lower limb and pelvis movement during walking in patients with hallux valgus before and after surgery.
  • Seventeen females with hallux valgus, who underwent first metatarsal osteotomy (bone shaving), constituted the experimental group.
  • The results showed that after hallux valgus surgery:
    • the walking speed decreased even more
    • Asymmetry in the hip and the pelvis movements in the frontal plane (present preoperatively) persisted after surgery.
  • Conclusion: Hallux valgus is not an isolated problem of the first toe, which could be just surgically addressed by correcting the foot’s alignment.1

A paper in the April 2017 edition of the journal Arthroscopy techniques suggests that “the underlying reason for recurrence of hallux valgus deformity after bunion surgery is multifactorial and includes surgeon-based and patient-based factors as well as original components of deformity initially unaddressed at the index procedure.”2

In other words, the surgeon did not address the problem causing the hallux valgus deformity and the patient is predisposed to factors of degenerative joint disease. In our opinion these are the tell-tale signs of degenerative joint disease from joint instability from ligament weakness. Surgery does not address ligament weakness.

Prolotherapy for bunions

Research like that above and due to a lack of consensus on the efficacy of surgery and other conservative treatments, patients are considering alternative methods, including Prolotherapy. Because first MTP joint pain is difficult to manage, this study investigated Dextrose Prolotherapy injections in order to establish the efficacy of this treatment with a study group and, subsequently, with patients afflicted with several painful conditions.

Bunions are an overgrowth of bone at the first metatarsophalangeal joint caused by degenerative joint disease from joint instability from ligament weakness. When ligaments weaken, the bones move. This is visually evident because bunions are a result of a gross displacement of the bone. Bone movement due to ligament laxity causes the bones to hit each other. This hitting causes an overgrowth of bone, as an attempt to stabilize the joint.

In our study patients complaining of diffuse big toe pain were treated with Prolotherapy. In the days following the procedure, patients were allowed to return to normal non-strenuous activities. Patients were advised to avoid such medications as ibuprofen, which block the inflammatory process. However, we did approve of the use of acetaminophen-based analgesia. Patients returned for treatment every four weeks, depending on their schedule, completing from 3 – 6 treatments.

  • After receiving injections, patients reported significant reduction in pain and stiffness.
  • Patients were asked to rate their pain levels on a scale of 0 to 10, with 0 being no pain and 10 being severe crippling pain.
  • All 12 patients reported pain as a symptom. Thus, patients were asked to report pain levels before and after Prolotherapy in these three categories:
    • 1) pain at rest,
    • 2) pain with normal activities, and
    • 3) pain with exercise.
  • Concerning 1) pain at rest: prior to Prolotherapy treatment, pain measurement scores averaged 4.42./10. After Prolotherapy treatment, pain measurement scores averaged less than 1/100th . Only one patient reported a VAS pain level of 1, and all others reported zero.
  • Concerning 2) pain with normal activities: prior to Prolotherapy treatment, pain measurement scores averaged 6.50.
    • Five of 12 patients could walk less than fifty feet without pain; seven of 12 could not walk a half-mile without pain; and ten of 12 could not walk a full mile.
    • After Prolotherapy, all but one patient reported no restrictions in walking any distance without pain, and a pain measurement average score of 1.17 was noted.
  • Concerning 3) pain with exercise: prior to Prolotherapy, five of 12 patients reported being severely compromised (only 0 to 30 minutes possible) in their ability to exercise, and a pain measurement scores of 7.42.
    • Of the twelve patients, two were totally compromised and unable to exercise; three were moderately (only 30 to 60 minutes possible).
    • Over half of the patients were severely to totally compromised in their athletic abilities prior to treatment.
    • After Prolotherapy, seven of 12 patients reported being able to exercise as much as they wanted without impediments and with satisfaction.

When comparing the three previous categories before and after Prolotherapy, all reached a statistically significant outcome.

Thus, this retrospective study, without a control group, demonstrates that Prolotherapy decreases pain and improves the quality of life for patients with metatarsophalangeal joint pain—unresolved by previous therapies, medications, and interventions.

As a result of Prolotherapy, eleven of 12 patients reported a greater than 75% improvement in the activities of daily living that continued to the end of the study. Of the two patients who were told they needed surgery, both felt sufficient pain relief with Prolotherapy to avoid surgery. After the study period, patients experienced overall improvement in range of motion, ability to walk and exercise, as well as relief of stiffness and numbness/burning.

Questions about Bunions and Metatarsophalangeal Joint Pain? Get help and inflammation from our Caring Medical staff 

1 Nakagawa R, Yamaguchi S, Kimura S, Sadamasu A, Yamamoto Y, Muramatsu Y, Sato Y, Akagi R, Sasho T, Ohtori S. Efficacy of foot orthoses as nonoperative treatment for hallux valgus: A 2-year follow-up study. Journal of Orthopaedic Science. 2018 Dec 1. [Google Scholar]


1 Klugarova J, Janura M, Svoboda Z, Sos Z, Stergiou N, Klugar M5. Hallux valgus surgery affects kinematic parameters during gait. Clin Biomech (Bristol, Avon). 2016 Dec;40:20-26. doi: 10.1016/j.clinbiomech.2016.10.004. Epub 2016 Oct 6. [Pubmed] [Google Scholar]

2. Lui TH. Correction of Recurred Hallux Valgus Deformity by Endoscopic Distal Soft Tissue Procedure. Arthroscopy techniques. 2017 Apr 30;6(2):e435-40. [Pubmed] [Google Scholar]

 

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