Hallux Rigidus

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Clinically Relevant Anatomy

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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

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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

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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

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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

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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

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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

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Key Evidence

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Resources

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Case Studies

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References

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