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Hallux Rigidus

Hallux Limitus

Hallux rigidus, a type of joint disorder, primarily affects the metatarsophalangeal (MTP) joint of big toe. It is a degenerative disease that causes pain along with stiffness in the affected area.


Presentation

Early signs and symptoms of hallux rigidus include the following [8]:

In addition to these, affected individuals would also experience certain additional symptoms as the condition progresses to more advance stages. These include:

  • Pain in the affected joint even at rest
  • Due to bone overgrowth there is significant amount of difficulty while wearing shoes
  • In severe cases, the individual would have to limp while walking
  • There is change in gait which causes development of pain in the back, knee and hip region
Pain
  • It is a degenerative disease that causes pain along with stiffness in the affected area.[symptoma.com]
  • Pooled results showed superiority of arthrodesis compared with total joint replacement for improving clinical outcome (by 43.8 versus 37.7 points on the AOFAS-HMI score) and reducing pain (a decrease of 6.56 versus 4.65 points on the VAS pain score).[ncbi.nlm.nih.gov]
  • - Clinical History: - Insidious onset of pain and stiffness about the great toe - Standing, walking & heels aggravate - worse at toe-off gait - relieved with rest - burning pain or paresthesia - Exam: - skin irritation due to pressure from footwear over[wheelessonline.com]
Surgical Procedure
  • GROWING POINTS: To assess whether benefits from surgery, validated and standardized measures should be used to compare the outcomes of patients undergoing standard surgical procedures.[ncbi.nlm.nih.gov]
Wound Infection
  • Complications included 1 superficial wound infection, and revision was performed in 5 feet (16%) because of loosening, sinkage, subluxation, pain, or fractured prosthesis. Implant survival was 92% at 5 years, 85% at 7 years, and 68% at 9 years.[ncbi.nlm.nih.gov]
  • There were 6 delayed unions and 7 wound infections in the fusions. Patient satisfaction was also higher in the fusion group. Raikin (2007) compared 21 BioPro hemiarthroplasties with a comparable historical control series of 27 fusions.[foothyperbook.com]
Prolonged Immobilization
  • immobilization Other Gouty arthritis Septic arthritis Neuromuscular derived muscle imbalance affecting first ray Treatment Stage 1, 2 – Functional Orthotics Most patients with early stage hallux rigidus complain of pain in and around the first MTP.[drpribut.com]
Italian
  • Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina. Abstract Hallux rigidus is a complex disorder, and numerous surgical procedures have been described for its management.[ncbi.nlm.nih.gov]
Foot Ulcer
  • KEYWORDS: diabetic foot ulcer; diabetic limb salvage; hallux limitus; infection; osteomyelitis; reulceration; surgical offloading[ncbi.nlm.nih.gov]
  • Over time, these joints and tissues will become strained, creating pain and fatigue, calluses , foot ulcers, bone spurs , and other conditions.[pafootdoctors.com]
Metatarsalgia
  • More recently the procedure has fallen out of favour, due to a high incidence of transfer metatarsalgia and poor function of the first MTP joint post-operatively.[ncbi.nlm.nih.gov]
Foot Pain
  • The postoperative perceptions of foot pain were comparable with the postoperative results from a range of previously published studies.[ncbi.nlm.nih.gov]
  • Our foot surgeon, an expert in stiff big toe treatment, will find the right options for you and ensure you are on the road to recovery from foot pain.[casteelfootandanklecenter.com]
  • My foot pain may not rule the rest of my life after all! I believe I'll make a sign that reads, "THE END IS NEAR!"[foot-pain-explained.com]
  • Get started on resolving your foot pain today. Fill in the form below to make an appointment at one of our clinics. Or ask our team a specific question here .[footmechanicspodiatry.co.nz]
Osteopenia
  • […] cyst formation/loose body formation Stage III: Established Arthrosis Severe dorsal exostosis (first metatarsal head and base of proximal phalanx) Irregular joint space narrowing Traction enthesiopathic sesamoid hypertrophy with immobilization induced osteopenia[drpribut.com]
  • Hypertrophy of the sesamoids in due to chronic traction, disuse osteopenia is seen, and degeneration parallels that of the MTP joint. Natural history Hallux rigidus is a fairly benign condition.[foothyperbook.com]
Long Arm
  • Among the procedures discussed are Keller arthroplasty, Keller interpositional arthroplasty, Bonney-Kessel, Mayo-Stone, Regnauld, Youngswick, Watermann, Watermann-Green, tricorrectional metatarsal osteotomy, sagittal V, LADO (long-arm decompression osteotomy[ncbi.nlm.nih.gov]
Muscle Contracture
  • Sesamoid dyscrasias, flexor plate injury or immobility, intrinsic muscle contracture, altered metatarsal head shape, short first metatarsal, long proximal phalanx, or a tight medial slip of the plantar fascia could each contribute to a limitation of plantar[drpribut.com]
Paresthesia
  • - Clinical History: - Insidious onset of pain and stiffness about the great toe - Standing, walking & heels aggravate - worse at toe-off gait - relieved with rest - burning pain or paresthesia - Exam: - skin irritation due to pressure from footwear over[wheelessonline.com]
  • […] arthritic predisposition Classification Presentation Symptoms first ray and 1st MTP pain and swelling worse with push off or forced dorsiflexion of great toe shoe irritation due to dorsal osteophytes and compression of dorsal cutaneous nerve may lead to paresthesias[orthobullets.com]

Workup

Early diagnosis is essential to arrest the progressive damage to the articular cartilage. A prior physical examination will be required, wherein the surgeon would move the foot in various directions to understand its range of motion and degree of damage to the area. Following this, radiographs would be indicated which show degenerative changes.

Treatment

In the early stages, non-surgical treatment approach is adopted to effectively manage the condition by controlling the symptoms.

Non-surgical approach:

  • Wearing comfortable footwear having ample room for the big toe
  • Women are advised against wearing high heels
  • Some individuals benefit with shoes having stiff soles
  • Inserting pads in the shoes can also help in limiting the movement of the toe
  • Heavy exercises and high impact activities like jogging should be avoided
  • Medication such as non-steroidal anti inflammatory drugs (NSAIDs) are employed for relieving pain and inflammation 
  • Ultrasound therapy or physical therapy helps in providing temporary relief

Surgery

Surgery is the last resort and employed in more advanced and severe cases when other treatment methods do not reduce pain and discomfort. Several types of surgical procedures are available to treat hallux rigidus. The type of method employed depends on the extent of damage and severity of symptoms experienced. In many cases, cheilectomy which employs shaving off the bone spur can help relieve pain and restore motility [10].

A procedure known as osteotomy may be required which involves cutting the bone in order to shorten the toe. Other surgical procedures include interpositional arthroplasty and arthrodesis which may be conducted depending on the condition [11]. Interpositional arthroplasty is helpful for younger patients. The procedure involves placing a spacer between the ends of joint; this helps in relieving pain and discomfort. Arthrodesis is employed in severe and more advanced stages.

Prognosis

Prognosis of the condition is quite favorable with patients responding well to the treatment regime used. Post treatment, patients can carry out daily activities with ease and can even exercise, run and wear all types of shoes comfortably. However, wearing shoes with high heels may be a cause of discomfort for individuals who have undergone fusion of toe [7].

Etiology

The exact etiology of hallux rigidus is unknown. However, trauma, structural abnormalities in the big toe combined with faulty biomechanics, are some of the factors known to cause hallux rigidus. Wear and tear in the first MTP joint is understood to be the major cause behind hallux rigidus.

Some research scholars have postulated the fact that repeated athletic activities leads to chronic gradual attenuation of the joint in the big toe; which subsequently paves way for development of osteoarthritis [2].

Epidemiology

It has been estimated that hallux rigidus is the second most common problem concerning the first MTP joint after hallux vagus. Majority of about 80% cases of hallux rigidus are bilateral in nature. More women are affected than men and the condition commonly strikes adults between the age group of 30 to 50 years [3] [4].

Sex distribution
Age distribution

Pathophysiology

The development and onset of hallux rigidus follows the principle of degenerative arthritis. Factors that cause undue stress on the articular cartilage include overuse of the joint, injury or faulty joint mechanics. These events gradually cause degeneration of the articular cartilage [5].

This in turn makes the joint more susceptible to wear and tear, thus making it more prone to injury. Such sequence of events causes increase in the subchondral density of bone, development of periarticular osteophytes and cystic changes. The formation of osteophytes causes considerable decrease in the MTP joint mobility with further degradation of normal joint mechanics. In more advanced or severe cases, articular cartilage undergoes denudation [6].

Prevention

Onset of hallux rigidus cannot be prevented. However, its progression can be arrested by doing simple exercises to improve joint mobility. Adequate rest and not overusing the joint also are some of the preventive measures that can be taken.

Summary

Hallux rigidus is a progressive disorder, and gradually causes the big toe to stiffen giving rise to condition known as frozen joint. It is a form of degenerative arthritis of the first metatarsophalangeal (MTP) joint of the foot, requiring prompt diagnosis and effective management. Females are more prone to suffer from the condition than males [1].

Patient Information

  • Definition: Hallux rigidus is characterized by development of stiffness along with pain in the joint of the big toe. The condition is also termed as stiff big toe.
  • Cause: Various factors give rise to the condition of hallux rigidus. Injury, repeated use of the joint which poses stress on the joint causes articular damage with subsequent degeneration. Faulty biomechanics of the joint can also increase the risk of hallux rigidus.
  • Symptoms: Affected individuals suffer from joint stiffness along with pain in the affected area. Individuals also experience great deal of difficulty while walking. In extreme cases, the pain aggravates in cold weather and there is gradual change in the gait of the individuals which forces them to limp while walking.
  • Diagnosis: A preliminary physical examination is carried out to determine the extent of motility of the joint of big toe. This is followed by an X-ray of the toe to identify degenerative changes in the joint.
  • Treatment: In initial stages, the condition can be managed by adopting a non-surgical approach which includes modifications in foot wear, and avoidance of high heels. Individuals are also given ultrasound and physical therapy to provide temporary relief. Medications are given to relieve pain and inflammation in the affected joint. Surgery is done during advanced stages.

References

Article

  1. Konkel KF, Menger AG, Retzlaff SA. Results of metallic Hemi-Great Toe Implant for Grade III and early Grade IV hallux rigidus. Foot Ankle Int. Jul 2009;30(7):653-60
  2. Jack EA. The aetiology of hallux rigidus. Br J Surg. 1940;27:492-7.
  3. Vilaseca RR, Ribes ER. The growth of the first metatarsal bone. Foot Ankle. Sep 1980;1(2):117-22.
  4. van Saase JL, van Romunde LK, Cats A, et al. Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations. Ann Rheum Dis 1989; 48:271.
  5. Altman RD, Fries JF, Bloch DA, et al. Radiographic assessment of progression in osteoarthritis. Arthritis Rheum 1987; 30:1214.
  6. Ahn TK, Kitaoka HB, Luo ZP, et al. Kinematics and contact characteristics of the first metatarsophalangeal joint. Foot Ankle Int. Mar 1997;18(3):170-4.
  7. Nilsonne H. Hallux rigidus and its treatment. Acta Orthop Scand. 1930;1:295-302.
  8. Zammit GV, Menz HB, Munteanu SE. Structural factors associated with hallux limitus/rigidus: a systematic review of case control studies. J Orthop Sports Phys Ther. Oct 2009;39(10):733-42
  9. Brennan SA, Harney T, Queally JM, et al. Influence of weather variables on pain severity in end-stage osteoarthritis. Int Orthop 2012; 36:643.
  10. Lau JT, Daniels TR. Outcomes following cheilectomy and interpositional arthroplasty in hallux rigidus. Foot Ankle Int. Jun 2001;22(6):462-70
  11. Barca F. Tendon arthroplasty of the first metatarsophalangeal joint in hallux rigidus: preliminary communication. Foot Ankle Int. Apr 1997;18(4):222-8

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Last updated: 2019-07-11 22:02