Hallux Rigidus (a.k.a. Hallux Limitus)
Summary
Hallux rigidus is essentially a progressive arthritis leading to stiffness and pain in the big toe joints [Figure 1A -1st MTP joint]. The loss of cartilage, which occurs first along the top half of this joint, is believed to be the result of repetitive jamming as the big toe joint attempts to move upward with each step. This can take many years to develop, but can become quite symptomatic. In the later stages of this disease process, cartilage covering the remainder of the joint surface also erodes, leading to a progressively worse and more bothersome arthritic joint.
Figure 1A: Hallux Rigidus Pain Location
Figure 1B: Great Toe Joint Bone Spur
Clinical Presentation
Patients with hallux rigidus will typically present with pain, stiffness, and swelling in the great toe joint. This is aggravated by activities that involve excessive repetitive upward movement of the big toe joint such as prolonged walking. Swelling usually occurs along the top half of the joint, and will be frequently associated with bone spur formation recognized as a ‘new prominence’ by the patient (See Figure 1B).
Physical examination will reveal limited and often painful motion in the big toe joint, particularly when the patient is weightbearing (See Figure #2). Prominent bone spurs [osteophytes] on the top part [dorsal aspect] of the joint are usually visible and palpable. It is very common to see these findings in both feet, although usually one foot is more symptomatic than the other. Tenderness to touch is common over the swollen great toe joint.
X-Rays
Weightbearing foot x-rays will typically identify some loss of first MTP joint cartilage, seen as narrowing of this space on the x-ray—as compared to other similar spaces seen in nearby unaffected joints. There may be squaring of the metatarsal head on the anterior and posterior view. The lateral view will often show a prominent dorsal bone spur (See Figure 3).
Figure 3A and 3B: Weight bearing x-rays showing Hallux Rigidus
Treatment
Non-Operative Treatment
In most cases, hallux rigidus can be successfully treated non-operatively. The principle of nonoperative treatment is to decrease the inflammation in the arthritic joint by limiting the motion through this joint. Successful non-operative management often involves:
Limiting great toe motion. The pain associated with movement of this joint can be limited with the use of a stiff-soled shoe with a slight rockerbottom contour. Alternatively, a rigid shank can be applied to the shoe, a foot plate may be inserted under the orthotic, or an orthotic with a Morton's extension (a.k.a. "Turf Toe Plate") can be used. Each of these serve to decrease or eliminate the painful motion of this great toe joint when affected by hallux rigidus.
Use of a wide-toe box made of soft material should also be used to allow more space for the great toe thereby limiting the irritation over the swollen toe.
Anti-inflammatory Medication. The use of an over the counter anti-inflammatory may also be helpful in improving symptoms.
Possible injection of corticosteroids. Short-term improvement of symptoms may alternatively be obtained with injection of a corticosteroid or hyaluronic acid derivative into the first MTP joint. Unfortunately, these treatments will not lead to predictable long-term improvement in the patient’s symptoms, and therefore have limited indications. They can, however, provide significant short-term relief—although they are not recommended for repetitive long-term use even if effective because of potentially cumulative side effects.
Operative Treatment
When patients fail non-operative management, reasonable operative options are available and should be considered. There are three broad categories of operative treatment. These include:
- 1st MTP joint dorsal cheilectomy (Bone spur removal).
- Fusion of the first MTP joint.
- First MTP joint arthroplasty [first MTP joint replacement].
*Edited August 31st, 2009