Hallux Rigidus

Original Editor - Tracy Hall

Top Contributors - Rachael Lowe, Tracy Hall, Laura Ritchie and Ilse De Bode  

Description

Hallux Rigidus (also referred to as Hallux Limitus) is a degenerative condition leading to reduced rang of motion in the first metatarsophalangeal (MTP) joint of the big toe or great toe. This can impair normal gait function, particularly during the propulsive phase.

Clinically Relevant Anatomy

The base of the the first MTP specifically is where the degenerative arthritis is typically found. The joint is covered with articular cartilage, a shiny covering to protect the ends of the bones within the joint. As this covering wears, degeneration occurs until bone is against bone. Bone spurs develop as part of this degenerative process and movement decreases. Normal range of motion is between 65 to 100 degrees.

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Mechanism of Injury / Pathological Process

Hallux Rigidus is a progressive disorder where the great toe’s motion is decreased over time. Some causes are faulty function or biomechanics and structural abnormalities such as displaced sesamoid bones as a result of Hallux Valgus. Over time this leads to osteoarthritis and reduced range of movement in the joint.

Clinical Presentation

Pain, stiffness and loss of motion are the some signs of hallux rigidus. Burning pain and paraesthesia can be present. Walking, standing and wearing heels aggravate the pain. Symptoms are relieved by rest.

The normal dorsiflexion range of motion of the first MTP joint is at least 65 degrees[2][3][4][5].  Nawoczenski, et al[6] showed a new standard of “normal” range of dorsiflexion range of motion of the great toe joint should now be set at approximately 45 degrees. However, this dorsiflexion range has only been verified for walking gait, not running.

Diagnostic Procedures

Hallux rigidus XR.jpg

Weight bearing, anterior posterior and lateral radiographs are usually needed to examine the joint. Often non-uniform joint space narrowing, widening or flattening of the 1st MT head is seen. Subchondral sclerosis or cysts, horseshoe shaped osteophytes, lateral greater than medial osteophytes and sesamoid hypertrophy may be seen.

A clinical/radiographic grading system was described by Regnauld and appears mainly in the European literature.

Hattrup and Johnson[7] described a radiographic classification which has become standard, and in fact correlates quite well with the Regnauld grading:

  • Grade 1: mild to moderate osteophytes formation but good joint space preservation
  • Grade 2: moderate osteophyte formation with joint space narrowing and subchondral sclerosis
  • Grade 3: marked osteophyte formation and loss of the visible joint space, with or without subchondral cyst formation

Coughlin et al[8] modified the Hattrup and Johnson classification to create the Coughlin and Shurnass[9] classification:

  • Grade 0:
    • Dorsiflexion 40-60°
    • Normal radiography
    • No pain
  • Grade 1
    • Dorsiflexion 30-40°
    • Dorsal osteophytes
    • Minimal/ no other joint changes
  • Grade 2
    • Dorsiflexion 10-30°
    • Mild to moderate joint narrowing or sclerosis
    • Osteophytes
  • Grade 3
    • Dorsiflexion less than 10°
    • Severe radiographic changes
    • Constant moderate to severe pain at extremities
  • Grade 4
    • Stiff joint
    • Severe changes with loose bodies and osteochondritis dissecans

Examination

  • Look for other features of systemic arthropathy.
  • Assess the overall foot shape, range of ankle dorsiflexion and function of the other foot joints Identify sites of tenderness – is the osteophyte symptomatic?
  • Evaluate the severity of rigidity and the residual arc of movement.  Is pain provoked mainly by dorsiflexion, plantarflexion or throughout the range of movement?
  • Check the alignment of the great toe, looking for IPJ hyperextension or hallux rigidus with valgus.  Are there any lesser ray problems?

Outcome Measures

  • Visual analog scales
  • AOFAS (American Orthopaedic Foot and Ankle Society) scores
  • Subjective self assessment score
  • MTP dorsiflexion
  • MTP total motion

Management / Interventions

Nonsurgical or conservative approaches:

Treatment for mild or moderate causes of Hallux rigidus includes anti-inflammatory NSAIDS medications that are often prescribed and usually start to relieve some symptoms with in three to four days. Glucosamine chondrointin sulfate, vitamins and minerals are recommended. Molded stiff inserts with rigid bar or rocker bottom shoes usually begin to help with in a few weeks. Shoes with a large toe box and cessation of high heels , kneeling or excessive squatting may help. Cortisone injections give relief with in 24 hours but often are only temporary.

Physical therapy to provide joint mobilizations, manipulation, range of motion, muscle reeducation, strengthening of the flexor hallucis longus muscles as well as the plantar intrinsics muscles of the feet can improve stability of the 1st MTP. Gait training for stage 1 and 2 (protection, rest, ice, compression and elevation) is often helpful to reduce the inflammation during initial stages. All of these measures can be of value to the patient even if he or she ultimately undergoes surgery.
Runners with stage II and greater hallux rigidus may need to switch to lightweight day hikers and switch from asphalt to dirt trails for long distance running.
Using rocking-soled shoes may also improve the step length of people with a hallux rigidus (level of evidence: 5). [10]

The primary goal of foot orthotic therapy or shoe modification should be blocking or shielding the hallux from dorsiflexion at the first metatarsal.

(level of evidence: 5) [11]
(level of evidence: 5) [12]

Surgical therapy:

The indication for surgery is intractable pain isolated to the first metatarsophalangeal joint that is refractory to shoe modification, use of rigid shoe inserts, nonsteroidal anti-inflammatory medications, and modification of activities. Choice depends on the stage of involvement, the limitations in range of motion, the activity level of the patient and the preferences of the surgeon and patient.

Types of surgery include:

  • Cheiloectomy - A procedure to remove bone spurs at the top of the joint allowing greater toe extension and improved walking. Usually beneficial for mild to moderate disease with less than 50% of joint affected usually grade 1 and grade 2[13][7][14][15].
  • Dorsiflexion phalangeal osteotomy - In patients with a reasonable range of motion, a dorsal wedge osteotomy of the phalanx increases dorsiflexion at a theoretical cost of loss of plantar flexion. Mild to moderate cases occasionally require this procedure.
  • Metatarsal Osteotomy – a slice is removed from the dorsal limb to slide the head down and proximally. The Place for these procedures is uncertain and more complex than cheilectomies. These procedures are intended for use in early hallux rigidus
  • Excision Arthroplasty or Keller procedure[16][13]The Keller procedure is when resection of the base of the proximal phalanx and soft-tissue reconstruction is performed with the intention to decompress the joint and improve pain and range of movement. The Keller procedure may lead to great toe weakness, cock-up deformity and metatarsalgia[17].
  • MTP Arthrodesis -  This is a procedure is performed to fuse the joint surfaces and is a favored procedure[18]. Suitable for most cases and severity but usually grades 3 and 4 are recommended[15] .Suitable as salvage when other procedures have failed (for example Keller procedure) Arthrodesis of the first MPJ consistently show superior results and patient satisfaction in comparison to other surgical options. While cheilectomy may be beneficial for early stages of hallux rigidus, arthrodesis of the first MPJ appears to be the best option for the relief of symptoms with stage III and stage IV hallux rigidus in active, athletic patients[19].
  • Artificial joint replacement- A procedure to replace joint surfaces with a plastic or metal surface. This technique of soft-tissue interposition arthroplasty gave excellent pain relief and reliable function of the hallux, and is an alternative treatment to MTP arthrodesis in select cases of severe hallux rigidus[20].  The downside to this is the joint may not last a life time and there is currently no study documenting the long-term performance of any first MTP joint prosthesis in running athletes

Differential Diagnosis

Turf toe, fracture, gout, rheumatoid arthritis could be some other causes of pain and stiffness in the 1st MTP joint.

Resources

Richie D. How To Treat Hallux Rigidus In Runners. 4 April 2009. Available from: www.podiatrytoday.com/how-to-treat-hallux-rigidus-in-runners. [last accessed 5/6/9]

Foot and Ankle Center of Washington, Seattle. Available at www.footankle.com/Hallux-Rigidus.htm [last accessed 24/5/9].

References

  1. SLO Motion Shoes. Hallux Rigidus: Causes, Diagnosis, and Treatment. Available from: http://www.youtube.com/watch?v=umCSpwEvWUM [last accessed 06/01/17]
  2. Root ML, Orien WP, Weed JH. Normal and abnormal function of the foot. In Clinical Biomechanics, vol II, Clinical Biomechanics Corp., Los Angeles, 1977
  3. Buell T, Green D, Risser J. Measurement of the first metatarsophalangeal joint range of motion. JAPMA 78:439, 1988.
  4. Bojsen-Moller F, Lamoreux L. Significance of free dorsiflexion of the toes in walking. Acta Orthop Scand 50: 471, 1979
  5. Hetherington VJ, Johnson RE, Albritton JS. Necessary dorsiflexion of the first metatarsophalangeal joint during gait. J Foot Surg 29:218, 1990
  6. Nawoczenski DA, Baumhauer JF, Umberger BR. Relationship between clinical measurements and motion of the first metatarsophangeal joint during gait. J Bone Joint Surg 81(3): 370-6, 1999.
  7. 7.0 7.1 Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment with cheilectomy. Clin Orthop 1988;226:182-91
  8. Coughlin MJ et al. Hallux rigidus. JBJS 2003; 85A:2072-88
  9. Coughlin MJ and Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2003; 24(10): 731-43.
  10. Cusack, G. Shtofmakher, R. L. Kilfoil Jr, S. Vu, “Improved step length symmetry and decreased low back pain with the use of a rocking-soled shoe in a patient with unilateral hallux rigidus”, BMJ Case Rep, September 2014 [Online] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166235/pdf/bcr-2014-206408.pdf (Level of evidence: 5)
  11. Correct Toes. Spread Your Toes™ Series: Hallux Limitus Conservative Care vs. Conventional Care. Available from: http://www.youtube.com/watch?v=iTFn1Ldq1G8 [last accessed 06/01/17] (Level of evidence: 5)
  12. Joan Hope Craig. Functional hallux mobilization. Available from: http://www.youtube.com/watch?v=ZOur5I0RTVo [last accessed 06/01/17] (Level of Evidence: 5)
  13. 13.0 13.1 Mann RA, Clanton TO. Hallux rigidus: treatment by cheilectomy. J Bone Jt Surg 1988; 70A:400-6
  14. Gould N. Foot and Ankle.1981 May; 1(6):315-20.
  15. 15.0 15.1 Michael J. Coughlin and Paul S. Shurnas. Hallux Rigidus. Grading and Long-Term Results of Operative Treatment. J. Bone Joint Surg. Am., Nov 2003; 85: 2072 - 2088.
  16. Keller's arthroplasty. J Bone Jt Surg 1990; 72B:839-42
  17. Blewett N, Greiss ME. Long-term outcomes following Keller’s excision arthroplasty of the great toe. Foot 1993; 3:144-7
  18. Brodsky JW, Baum BS, Pollo FE, Mehta H. Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus. Foot Ankle International. 2007 Feb;28(2):162-5
  19. DP O'Doherty, IG Lowrie, PA Magnussen, and PJ Gregg. The management of the painful first metatarsophalangeal joint in the older patient. Arthrodesis or Keller's arthroplasty? Journal of Bone and Joint Surgery - British Volume, 72-B(5), 839-842
  20. Coughlin MJ, Shurnas PJ. Soft-tissue arthroplasty for hallux rigidus. Foot Ankle International. 2003 Sep;24(9):661-72.