Hallux rigidus (HR), a degenerative osteoarthritic condition of the 1st MTP joint, or hallux, is characterized by a loss of joint extension. Most of us will have some degree of HR during our life, but only a few will develop localized symptoms. This issue of the CWG newsletter looks at HR from three viewpoints: assessment, etiology, and treatment. The role of HR in the development of other secondary conditions will also be discussed briefly.
Note localized pain during or after increased activity, or occasional swelling after activity. Severe cases can be occasionally confused with acute gout, but joint is rarely hot, red and exquisitely tender with HR. One or more osteophytes at the distal and dorsomedial end of the 1st metatarsal may be present and may be locally reddened from shoe contact. These osteophytes are sometimes mistaken for bunions which are more medial. Tenderness is found along the 1st MTP joint line, usually near the osteophytes. Passive extension may be mildly or severely limited. Crepitus and pain may also be present. In most cases of HR pain is usually elicited by passively flexing the toe, ausing the synovial tissue on the superior aspect of the joint to be stretched over the osteophytes. The joint capsule, which has tightened to match the osseous block of HR, further restricts joint motion.
Gait: The greater the degree of HR, the more the patient must compensate during gait. In order for the body to pass over the foot, the hallux must extend, and the faster a person goes, the more extension required. The HR patient will supinate the foot, externally rotate the hip to turn the foot out, or hike the knee excessively to avoid having to walk over the restricted joint. It is important to note that these compensations result in abnormal stress on other joints and tissues.
Etiology: HR results from one or more of the following factors: (1) injury, such as turf toe in sports or any attempt to move large objects with their big toe (a feat many humans will try at some point in their lives); (2) bunions, associated with a hallux valgus angle, resulting in abnormal osseous articulation; (3) hyperpronation, resulting in excessive medial weight bearing, once again resulting in early wear and tear of the joint surfaces; (4) normal joint wear and tear is also a factor, which is difficult to determine in a joint that often experiences a variety of accelerated osteoarthritic changes.
Accommodating the lack of extension, and normalizing the direction of forces on the1st MTP joint are the most effective methods of treating HR. The limited life of cellastic joint replacements makes a case for a non-surgical approach, especially in middle-aged and active patients. Reducing the heel height of women’s dress shoes to a comfortable level is essential. Minimizing squatting movements will help. Hyperpronators will be treated first with orthotics or arch supports, and supportive, rocker-soled footwear. Where hyperpronation is not a factor, rigid rocker soled shoes will reduce the demand for extension on the joint. Wooden shoes work in much the same way if you can obtain them. In severe cases, and for many sporting activities, CWG installs a carbon graphite stiffener in the sole of the shoe, or in some cases, an internal splint. After applying these techniques, many patients who have almost no motion in their great toe can enjoy tennis or other sports requiring extensive joint mobility. We also teach traction techniques to our patients to mobilize the associated tight joint capsule, often with excellent results.
Surgical techniques can also be applied to HR. Joint fusion creates a painfree joint and is well suited for inactive patients. Cheilectomy, or partial removal of only portions of the joint surfaces, is preferred by many surgeons as it leaves much of the joint’s surface intact without shortening the 1st metatarsal, and offers an improved range of motion. Surgical results can be enhanced with pedorthic footwear modifications and orthotics.
The body develops many subtle adaptations to get around various complaints, such as HR. Over time, however, these compensations abnormally stress other joints in favour of the affected ones. Long standing HR typically forces weight-bearing more laterally, resulting in related conditions like lesser metatarsalgias, lateral midtarsal complaints, lateral knee complaints in runners, and even various hip complaints. Turning the foot out is also less demanding on the great toe, but promotes medial knee and foot weight bearing. So if a patient presents with any foot, knee or hip condition, check for HR.
** The above information is not intended to replace a physicians advice. Seek a physicians advice first.