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Hallux Rigidus

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Other Names

  • Degenerative joint disease of the first metatarsophalangeal joint
  • Arthritis of the first metatarsophalangeal joint
  • Osteoarthritis of the first toe
  • Arthritis of the first MTP

Background

History

Epidemiology

  • Most common form of arthritis of the foot[1]
  • Nearly 10% of adults have symptomatic hallux rigidus[2]
    • Radiographic evidence is present in 20% to 48% of adults older than 40 years

Pathophysiology

  • General
    • Degenerative joint disease of the 1st MTP characterized by pain, stiffness

Etiology

  • General
    • Primarily considered an idiopathic disease with multiple risk factors
    • Underlying cause is typically multifactorial
  • History of trauma
    • Individuals that have repetitive microtrauma to the foot[3]
    • Single acute event[4]
    • Hyperextension injuries to the plantar plate[5]
  • Biomechanical factors
    • Metarsus primus elevatus
    • Hallux valgus
    • First ray hypermobility
    • Metatarsus adductus
  • Non-contributatory[6]
    • Achilles contracture
    • Shoe wear
    • Elevated metatarsal head

Pathoanatomy


Risk Factors

  • Demographic
    • Family History
      • 2/3 of patients have a positive family history[7]
      • 95% of patients with a family history had bilateral symptoms
    • Women
  • Sports
    • Soccer
    • Runners
    • Ballet

Differential Diagnosis


Clinical Features

Radiograph of foot showing joint space narrowing, subchondral sclerosis and dorsal osteophyte formation of the 1st MTPJ[8]
  • History
    • Pain at the first metatarsophalangeal joint, especially while walking or with push off
    • Pain is typically worse dorsally
    • Swelling, dorsal osteophytes and soft tissue prominence
    • Decreased range of motion, stiffness
    • Pain while wearing tight shoes
    • Pain after standing for prolonged periods
    • When walking, symptoms most severe at terminal heel-rise just before toe-off
    • Pain after loading 1st MTPJ such as tip-toeing, running, stairs, push ups[9]
    • Antalgic gait or limp is often present
    • Lateral foot pain may develop due to altered gait and walking on lateral foot
    • Neuropathic pain from compression of the dorsomedial branch of the superficial peroneal nerve[10]
    • Chronically, the joint may ankylose naturally and eventually become painless
  • Physical Exam: Physical Exam Foot
    • Swollen, inflamed first MTPJ
    • Tender osteophytes on dorsal surface
    • Limited range of motion
    • Pain in dorsiflexion (due to dorsal osteophyte impingement)[11]
    • Pain in plantarflexion (stretching of the dorsal capsule over the dorsal osteophyte)
    • Decreased push off strength
    • Compare to unaffected foot if symptoms unilateral
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Standard weight bearing 3 views
  • Findings on lateral view
    • Dorsal osteophytes
    • Joint space narrowing
  • Findings on AP view
    • Subchondral sclerosis
    • Subchondral cysts
    • Flattening of the metatarsal head
    • Joint space narrowing

Classification

Coughlin and Shurnas Classification

Grade Dorsiflexion Radiographic findings Clinical findings
0 40-60° and/or 10-20% compared to other side Normal No pain; only stiffness and loss of motion on examination
1 30-40° and/or 20-50% loss compared to other side Dorsal osteophyte is main finding, minimal joint-space narrowing, minimal peri-articular sclerosis, minimal flattening of metatarsal head Mild or occasional pain and stiffness, pain at extremes of dorsiflexion and/or plantar flexion on examination
2 10-30° and/or 50-75% loss compared to other side Dorsal, lateral and possible medial osteophytes giving flattened appearance to metatarsal head, no more than of dorsal joint space involved on lateral radiograph, mild-to-moderate joint space narrowing and sclerosis, sesamoids not usually involved Moderate to severe pain and stiffness that may be constant; pain occurs just before maximum dorsiflexion and maximum plantar flexion on examination
3 <10° and/or 75-100% loss compared to other side. There is notable loss of plantar flexion as well. Same as in grade 2 but with substantial narrowing, possibly with periarticular cystic changes, more than of dorsal joint space involved on lateral radiograph, sesamoids enlarged and/or cystic and/or irregular Nearly constant pain and substantial stiffness at extremes of range of motion but not at midrange
4 Same as in grade 3 Same as in grade 3 Same criteria as in grade 3 BUT there is definite pain in mid-range of passive motion

Management

Nonoperative

  • Indications
    • Vast majority of cases
  • Ice
  • Analgesics
  • Shoe Modification
    • Optimal shoe has deep toe box (decrease contact on dorsal osteophytes), stiff sole with limited movement of 1st MTPJ
    • Shoe rocker sole may decrease movement by causing a rolling transition between heel-strike and toe-off.
    • Wide toe shoe
    • Avoid high heels
  • Orthotics
    • Goal: stiffen shoe, limit dorsiflexion of 1st MTPJ[12]
    • Footplate made of spring-steel or carbon fibre
    • Extended shank
    • Morton's Extension: limits movement at the hallux, better tolerated by active patients
  • Activity modification
    • Avoidance of activities that cause repetitive dorsiflexion of the first MTP
    • This includes running, jumping, and traveling upstairs
  • Corticosteroid Injection
    • Commonly used, likely beneficial with less severe arthritis
    • When combined with manipulation under anesthesia, appears to help relieve symptoms and delay surgery in grade 1 and 2 disease, but not grade 3/4[13]
  • Hyaluronic Acid
    • RCT of 151 patients failed to show any reduction in pain at 3 months compared to placebo[14]

Surgical Management

  • Indications
    • When conservative management fails
  • Technique
    • Joint debridement (Cheilectomy)
    • MTPJ Arthrodesis
    • Moberg osteotomy
    • Watermann osteotomy
    • Youngswick osteotomy
    • Keller resection arthroplasty
    • MTPJ arthroplasty
    • Salvage arthrodesis

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications & Prognosis

Prognosis

  • Nonsurgical management
    • One study of 700 patients reported a success rate of 55%[15]

Complications

  • Chronic foot pain

See Also


References

  1. van Saase, JL, van Romunde, LK, Cats, A, Vandenbroucke, JP, Valkenburg, HA. Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations. Ann Rheum Dis. 1989;48(4):271–280.
  2. Roddy, E, Thomas, MJ, Marshall, M. The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the clinical assessment study of the foot. Ann Rheum Dis. 2015;74(1):156–163.
  3. Coughlin MJ. Conditions of the forefoot. In: DeLee J, Drez D, eds. Orthopaedic sports medicine: principles and practice. Philadelphia: WB Saunders, 1994; P221e44.
  4. Shurnas P, Coughlin M. Arthritic conditions of the foot. In: Surgery of the foot and ankle. Philadelphia: Elsevier, 2007; 867e909.
  5. McMaster MJ. The pathogenesis of hallux rigidus. J Bone Joint Surg Br 1978; 60B: 82e7.
  6. Coughlin, MJ, Shurnas, PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am. 2003;85-A (11):2072–2088.
  7. Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2003; 24: 731e43.
  8. Case courtesy of The Radswiki, Radiopaedia.org, rID: 11470
  9. Kunnasegaran R, Thevendran G. Hallux rigidus: nonoperative treatment and orthotics. Foot Ankle Clin 2015; 20: 401e12.
  10. Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int 2008; 29: 637e46.
  11. Hamid KS, Parekh SG. Clinical presentation and management of hallux rigidus. Foot Ankle Clin 2015; 20: 391e9.
  12. Sammarco VJ, Nichols R. Orthotic management for disorders of the hallux. Foot Ankle Clin 2005; 10: 191e209.
  13. Solan MC, Calder JD, Bendall SP. Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg Br 2001; 83: 706e8.
  14. Munteanu SE, Zammit GV, Menz HB, et al. Effectiveness of intraarticular hyaluronan (Synvisc, hylan G-F 20) for the treatment of first metatarsophalangeal joint osteoarthritis: a randomised placebo-controlled trial. Ann Rheum Dis 2011; 70: 1838e41.
  15. Grady JF, Axe TM, Zager EJ, Sheldon LA. A retrospective analysis of 772 patients with hallux limitus. J Am Podiatr Med Assoc 2002; 92: 102e8.
Created by:
John Kiel on 20 June 2019 21:15:13
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Last edited:
4 October 2022 12:42:28
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