Hallux Rigidus

Original Editor - Tracy Hall

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Clinically Relevant Anatomy

add text here relating to clinically relevant anatomy of the condition

Clinical anatomy: The” Big toe”, Great toe or the first metophalangeal joint is where this condition called Hallux rigidus occurs. 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 bone ends As this covering wears degeneration occurs until bone is against bone. Bone spurs develop as part of this degeneration process and movement is decreased. Normal range of motion is speculated between 65 to 100 degrees. 

Mechanism of Injury / Pathological Process

add text here relating to the mechanism of injury and/or pathology of the condition
Hallux Rigidus is a progressive disorder. The toe’s motion is decreased over time. Some causes are faulty function or biomechanics and structural abnormalities. Wear and tear over time can lead to osteoarthritis in the joint.

Clinical Presentation

add text here relating to the clinical presentation of the condition
Pain, stiffness and loss of motion are the some signs of hallux rigidtus. Burning pain and parasthesia 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 MPJ is at least 65 degrees by Root, et al., many other authors (Joseph, Buell, Bojsen-Moller, Hetherington) Nawoczenski, et al. 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

add text here relating to diagnostic tests for the condition
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. Subchondrral sclerosis or cysts, horseshoe shaped osteophytes, lateral greater than medial osteophytes and seasamoid hypertrophy may be seen. A clinical/radiographic grading system was described by Regnauld and appears mainly in the European literature. Hattrup and Johnson (1988) described a radiographic classification which has become standard, and in fact corelates 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 (2003) modified the Hattrup and Johnson classification
Coughlin and Shurnass classification:
• Grade 0:
o Dorsiflexion 40-60°
o Normal radiography
o No pain
• Grade 1
o Dorsiflexion 30-40°
o Dorsal osteophytes
o Minimal/ no other joint changes
• Grade 2
o Dorsiflexion 10-30°
o Mild to moderate joint narrowing or sclerosis
o Osteophytes
• Grade 3
o Dorsiflexion less than 10°
o Severe radiographic changes
o Constant moderate to severe pain at extremities
• Grade 4
o Stiff joint
o 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

add links to outcome measures here (see Outcome Measures Database) 

Visual analog scales, AOFAS (American Orthopaedic Foot and Ankle Society)scores, Subjective self assessment score, MTP dorsiflexion, MTP total motion , and presentation of callus are examined

Management / Interventions

add text here relating to management approaches to the condition
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 chondriontin 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 ist 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.
The primary goal of foot orthotic therapy or shoe modification should be blocking or shielding the hallux from dorsiflexion at the first metatarsal.
The indication for surgery was intractable pain isolated to the
first metatarsophalangeal joint that was refractory to shoe
modifications, use of rigid shoe inserts, nonsteroidal antiinflammatory
medications, and modification of activities.
Surgical therapy: The indication for surgery is intractable pain isolated to the first metatarsophalangeal joint that is refractory to shoe motification, use of rigid shoe inserts, nonsteroidal antiinflammatory 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 proceedure 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.
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 proceedure.

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:
The technique involves resection or reaming of the base of the proximal phalanx and metatarsal head to decompress the first MTP joint and placement of a soft-tissue tendon bundle as a biologic spacer. The technique has a high complication rate and is generally not recommended. The Keller procedure may lead to great toe weakness, cock-up deformity and metatarsalgia. It is favored for some advanced cases.
MTP Arthrodesis:
This is a proceedure is performed to fuse the joint surfaces and is a favored proceedure .Suitable for most cases and severity but usually grades 3 and 4 are recommended .Suitable as salvage when other procedures have failed (for example Keller procedure) The Keller proceedure 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.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. A randomized controlled trial by O’Doherty et al (1990) found no difference in functional outcome between arthrodesis and Keller arthroplasty in 81 patients over the age of 45 (some of whom had hallux valgus in addition to OA). Fusion remains the gold standard for the management of end-stage hallux rigidus; it is cheaper and simpler than arthroplasty and no study has yet shown advantage for the extra cost.
Artificial joint replacment-
A proceedure to replace joint surfaces with a plastic or metal surface. 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 MPJ prosthesis in running athletes

Differential Diagnosis

add text here relating to the differential diagnosis of this condition
Turf toe, fracture, Gout RA could be some other causes of pain and stiffness in the 1st MTP joint Hallux Valgus

Key Evidence

add text here relating to key evidence with regards to any of the above headings
________________________________________
Hattrup-SJ; Johnson-KA Department of Orthopedics, Mayo Clinic, Rochester, Minnesota. Clin-Orthop. 1988 Jan (226): 182-91
The records of 58 patients who had hallux rigidus and were treated with cheilectomy between 1977 and 1984 showed the following results: 53.4% completely satisfactory, 19% mostly satisfactory, 27.6% unsatisfactory. No deterioration of results with time was apparent. When the results were analyzed in relation to the degenerative changes that were evident in the preoperative roentgenograms, the failure rate was increased from 15% with Grade I changes to 37.5% with Grade III changes. Cheilectomy is the procedure of choice in patients with hallux rigidus and Grade I changes.
________________________________________
Mann-RA; Clanton-TO University of Texas Health Science Center, Houston 77030. J-Bone-Joint-Surg-Am. 1988 Mar; 70(3): 400-6
Cheilectomy, the excision of an irregular osseous rim that interferes with motion of a joint, was performed on the distal part of the first metatarsal of twenty-five patients who had hallux rigidus. Relief of pain was achieved in all but three patients, whose cases were considered as failures. Joint motion improved by an average of 20 degrees, and it was in an acceptable range in twenty-three patients. There were no complications other than persistence of swelling in six patients. No patient required additional operative intervention during an average follow-up of fifty-six months. We concluded that cheilectomy is a better method of treatment for hallux rigidus than arthrodesis, resection arthroplasty, or arthroplasty with the use of a flexible implant.
________________________________________
Gould N. Foot & Ankle. [JC:f3x] 1(6):315-20, 1981 May.
Fifty-one feet in 42 patients with varying degrees of symptomatic hallux rigidus and with 2 years of follow-up have been operated with excellent results. Cheilotomy was performed in all cases with only cheilotomy employed in the young patients and implant surgery (single-stem silicone) reserved for the older and more advanced arthritis cases. Pain generally disappeared within 3 months. Range of toe motion in dorsiflexion increased. All patients returned to their activity of choice. All patients were able to utilize off-the-shelf footwear postoperatively. There have been no fractures or inflammatory reactions of the implants as yet, including those inserted 4 or more years ago. 

GRADING AND LONG-TERM RESULTS OF OPERATIVE TREATMENT
BY MICHAEL J. COUGHLIN, MD, AND PAUL S. SHURNAS, MD

This is a long-term study over 1 nineteen year period documenting and evaluating the outcome of surgical treatment of hallux rigidus in ones surgeon’s practice. Assessment of a clinical grading system for use in the treatment of hallux rigidus was examined..
Methods: All patients in whom degenerative hallux rigidus had been treated with cheilectomy or metatarsophalangeal joint arthrodesis between 1981 and 1999 and who were alive at the time of this review were identified and invited to return for a follow-up evaluation. At this follow-up evaluation, the hallux rigidus was graded with a new five grade clinical and radiographic system. Outcomes were assessed by comparison of preoperative and postoperative pain and AOFAS (American Orthopaedic Foot and Ankle Society) scores and ranges of motion. These outcomes were then correlated with the preoperative grade and the radiographic appearance at the time of follow-up.
Results: One hundred and ten of 114 patients with a diagnosis of hallux rigidus returned for the final evaluation. Eighty patients (ninety-three feet) had undergone a cheilectomy, and thirty patients (thirty-four feet) had had an arthrodesis. The mean duration of follow-up was 9.6 years after the cheilectomies and 6.7 years after the arthrodeses. There was significant improvement in dorsiflexion and total motion following the cheilectomies (p = 0.0001) and significant improvement in postoperative pain and AOFAS scores in both treatment groups (p = 0.0001). A good or excellent outcome based on patient self-assessment, the pain score, and the AOFAS score did not correlate with the radiographic appearance of the joint at the time of final follow-up. Dorsiflexion stress radiographs demonstrated
correction of the elevation of the first ray to nearly zero. There was no association between hallux rigidus and hypermobility of the first ray, functional hallux limitus, or metatarsus primus elevatus.
Conclusions: Ninety-seven percent (107) of the 110 patients had a good or excellent subjective result, and 92% (eighty-six) of the ninety-three cheilectomy procedures were successful in terms of pain relief and function. Cheilectomy was used with predictable success to treat Grade-1 and 2 and selected Grade-3 cases. Patients with Grade-4 hallux rigidus or Grade-3 hallux rigidus with <50% of the \ metatarsal head cartilage remaining at the time of surgery should be treated with arthrodesis.For patients who desire preservation of motion and are willing to accept less than total pain relief, cheilectomy provides a high proportion of good and excellent long-term results. However, arthrodesis should be considered for patients who clearly have pain in the mid-range
of motion on examination. A high proportion of these patients can be expected to have a good or excellent long-term result

Soft-tissue arthroplasty for hallux rigidus.

Coughlin MJ, Shurnas PJ.

Regional Orthopaedic Health Care, Mountain Home, AR, USA. [email protected]

Seven patients (seven feet) were evaluated at an average follow-up of 42 months following soft-tissue interposition arthroplasty of the hallux metatarsophalangeal (MTP) joint for severe hallux rigidus. The technique involved reaming of the base of the proximal phalanx and metatarsal head to decompress the first MTP joint and placement of a soft-tissue tendon bundle as a biologic spacer. Six of seven patients had bilateral disease, and a positive family history of hallux rigidus. At final follow-up, all seven patients rated their result as good or excellent, the level of pain was substantially reduced, and the mean AOFAS score substantially improved from 46 to 86 points. Mild metatarsalgia was noted by four patients and characterized by mild plantar callosities in these cases. The mean MTP dorsiflexion improved from 9 degrees to 34 degrees and patients demonstrated good to excellent plantarflexion strength on manual muscle testing and with toe rise. Physical examination of the involved feet demonstrated no evidence of pes planus, metatarsus primus elevatus, Achilles tendon contracture, or metatarsocuneiform joint hypermobility in any of the seven. The technique of soft-tissue interposition arthroplasty as described 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.

Brodsky JW, Baum BS, Pollo FE, Mehta H.
BACKGROUND: Arthrodesis of the first metatarsophalangeal (MTP) joint is a common procedure with a proven long-term success rate. However, there is limited scientific information on its functional results. There is little data in the literature about changes in gait parameters after first MTP joint arthrodesis. The purpose of this study was to objectively evaluate the effects of first MTP joint arthrodesis on gait. METHODS: Twenty-three patients with symptomatic hallux rigidus refractory to nonoperative treatment were treated with first MTP joint arthrodesis. A prospective gait analysis study was performed on all patients at an average of 8.6 days before surgery and then again at least 1 year postoperatively. Preoperative and postoperative data from the patients were compared to determine differences in clinically relevant temporal-spatial, kinematic, and kinetic parameters of gait. RESULTS: There were three statistically significant changes in gait: increases in maximal ankle push-off power and single-limb support time on the involved extremity, and a decrease in step width. CONCLUSIONS: First MTP joint arthrodesis produces objective improvement in propulsive power, weightbearing function of the foot, and stability during gait.

Resources

add appropriate resources here 

Coughlin MJ, , Shurnas P. ; Grading and long term result of operative treatment; The Journal of Bone and Joint Surgery inc. 2003: 2072-2086.
Mann-RA; Clanton-TO University of Texas Health Science Center, Houston 77030. J-Bone-Joint-Surg-Am. 1988 Mar; 70(3): 400-6
Board T, Fox A, Barrie J ; East Lancashire Foot and ankle hyper book
Hattrup-SJ; Johnson-KA Department of Orthopedics, Mayo Clinic, Rochester, Minnesota. Clin-Orthop. 1988 Jan (226): 182-91
Gould M, Foot& ankle,{JC:f3x} 1(6):315

Case Studies

add links to case studies here (case studies should be added on new pages using the case study template)  Have not had ny cases of this condition
J Othrop Sports Phys Ther. 1999 Dec;29(12):727-35.
Nonoperative and operative intervention for hallux rigidus.
Nawoczenski DA
Department of Physical Therapy, Ithaca College, Rochester, NY 14623, USA. [email protected]

STUDY DESIGN: Case study of the management of an individual with hallux rigidus deformity. OBJECTIVE: To describe the outcome of nonoperative and operative treatment, including kinematic and kinetic changes following cheilectomy surgery, for an individual with hallux rigidus deformity. BACKGROUND: Hallux rigidus is a common disorder of the first metatarsophalangeal joint characterized by progressive limitation of hallux dorsiflexion, prominent dorsal osteophyte formation, and pain. Surgery may be considered when nonoperative management strategies have proven unsuccessful. Kinematic and plantar pressure changes during dynamic activities have not been previously described following cheilectomy surgery for hallux rigidus deformity. METHODS AND MEASURES: The patient was a 54-year-old man who sustained a traumatic injury to the great toe. Conservative treatment included nonsteroidal anti-inflammatory drugs, custom insole fabrication, and footwear outersole modification. Because of continued pain, loss of motion, and restrictions in daily activities, the patient elected to have surgery, and a cheilectomy procedure was done. Presurgical and postsurgical kinematic data of first metatarsophalangeal joint motion were collected using an electromagnetic tracking device during clinical motion tests and walking. Peak plantar pressures were assessed during gait. The patient was evaluated preoperatively, at 6 months, and again at 18 months following surgery. RESULTS: The outcome of surgery proved favorable, both subjectively and objectively. Peak dorsiflexion increased significantly (a minimum of 20 degrees) for all clinical tests and walking trials at the first metatarsophalangeal joint when compared with preoperative measurements. Peak plantar pressures also increased over the medial forefoot (68%) and hallux (247%) between preoperative testing and follow-up, indicating increased loading to this region of the foot. CONCLUSIONS: Restrictions in motion and daily activities and persistent pain may warrant surgical intervention for individuals with hallux rigidus deformity. A successful outcome, as measured by the patient's self-reported pain, return to recreational activities, and kinematic and plantar pressure changes at the follow-up examination, was demonstrated in this case study.

Recent Related Research (from Pubmed)

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1dSaW42H3lP07KcFFmgjndBS5c1UgGbfTltLqpcaU5PGxUpkR|charset=UTF-8|short|max=10: Error parsing XML for RSS

References

References will automatically be added here, see adding references tutorial.

Foot and Ankle Center of Washington, Seattle Available at Website www.footankle.com/Hallux-Rigidus.htm -Accessed May 24,2009
Coughlin MJ & Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2003; 24(10): 731-43.
Coughlin MJ et al. Hallux rigidus. JBJS 2003; 85A:2072-88
Mann RA, Clanton TO. Hallux rigidus: treatment by cheilectomy. J Bone Jt Surg 1988; 70A:400-6
Blewett N, Greiss ME. Long-term outcomes following Keller’s excision arthroplasty of the great toe. Foot 1993; 3:144-7
O'Doherty DP et al. The management of the painful first metatarsophalangeal joint in the older patient: arthrodesis or Keller's arthroplasty. J Bone Jt Surg 1990; 72B:839-42
Richie D. How To Treat Hallux Rigidus In Runners: 4 April 2009
]