Hallux Rigidus and Hallux Limitus

by Stephen M. Pribut, DPM

This is one of a series of articles discussing sesamoid injuries, hallux rigidus, hallux limitus, turf toe, and other, similar first metatarsophalangeal (MTP) joint injuries. The introduction is common for this series.

Ardipithecus Ramidus

Ardipithecus Ramidus

In evolution, the abduction of the first ray, disappearance of an opposable hallux, and realignment of the first metatarsophalangeal joint and first metatarsocuneiform joint marked a complete change from arboreal living to obligate bipedalism. Ardipithecus ramidus, the oldest known hominid, had an adducted first metatarsal, opposable hallux, and was able to walk in a bipedal manner (Lovejoy, Latimer et al. 2009). As Australopithecus evolved with a more modern alignment of the great toe, developed larger gluteal muscles, continued to evolve a longer Achilles tendon, hominids became obligate bipeds and were able to run.

The first metatarsophalangeal joint includes 4 bones. The most readily apparent portion of the joint is the articulation between the concave shaped base of the proximal phalanx and the convex, rounded head of the first metatarsal. The plantar surface includes the two sesamoid bones (fibular or lateral and tibial or medial) and the joint capsule. The joint capsule is reinforced on its plantar aspect by both a fibrocartilagenous plate and the plantar accessory ligament. The flexor hallucis longus and flexor hallucis brevis attach on the plantar aspect, along with the abductor hallucis muscle and the adductor hallucis muscle.

Dorsally the tendons of the extensor hallucis longus and the extensor hallucis brevis muscles insert.

Turf toe, sesamoiditis, and hallux rigidus are a functionally interconnected set of injuries. These problems can impair the ability to run. In severe cases a runner may consider giving up their sport permanently. We’ll examine these entities individually and review treatment.

Hallux Rigidus: Increasingly Stiff Big Toe

Description and definition:

Hallux rigidus refers to an absence of dorsiflexion at the first metatarsophalangeal joint. At times, the term hallux limitus has been used to describe the condition in which the dorsiflexion is not absolutely limited. Functional hallux limitus, was first described by Laird,(Laird 1972). Functional hallux limitus refers to biomechanical features of the joint which effectively limit dorsiflexion. Excessive pronation, a long first metatarsal, and several other factors may play a role in development of a functional hallux limitus.
Functional hallux limitus is a condition in which no degenerative changes are present. It is thought to be one of many possible etiological causes of Hallux Rigidus.

The term hallux limitus has been useful, over the past many years, to describe a limited range of dorsiflexion. However, the current trend is to only use the term hallux rigidus. Hallux rigidus was first described in 1887 by Davies-Colley, who used the term hallux flexus in referring to a plantar flexed posture of the phalanx relative to the metatarsal head.(Davies-Colley 1887) The term hallux rigidus was first used by Cotterill in 1888. (Cotterill 1888)

Grading systems which use both biomechanical features and x-ray criteria are helpful to stage hallux rigidus. The most useful classification system for hallux rigidus was suggested by Roukis (Roukis, Jacobs et al. 2002) and combines criteria from the systems of Drago, (Drago, Oloff et al. 1984) Hanft, (Hanft, Mason et al. 1993) and Kravitz (Kravitz 1994).

The following table describes a modification of these approaches.

Modified hybrid grading system for hallux rigidus

Stage I: Functional limitus
Metatarsus primus elevatus
Hallux equinus or flexus
Plantar subluxation of the hallucal proximal phalanx
Periarticular subchondral sclerosis
Minimal dorsal exostosis (first metatarsal head and base of proximal phalanx)
Minimal flattening of first metatarsal head

Stage II: Early joint adaptation
Moderate dorsal exostosis (first metatarsal head and base of proximal phalanx)
Moderate flattening of first metatarsal head
Minimal joint space narrowing
Subchondral joint sclerosis
Lateral first metatarsal head erosion, and/or joint flare/exostosis
Sesamoid hypertrophy ± Subchondral cyst formation/loose body formation

Stage III: Established Arthrosis
Severe dorsal exostosis (first metatarsal head and base of proximal phalanx)
Irregular joint space narrowing
Traction enthesiopathic sesamoid hypertrophy with immobilization induced osteopenia
Definite subchondral cyst formation and presence of loose bodies

Stage IV: Ankylosis
Exuberant exostosis proliferation, trumpeting of the first metatarsal head, base of the proximal phalanx, and sesamoid apparatus
Minimal/absent joint space
Sesamoid fusion
Hallucal interphalangeal and/or first metatarsal-medial cuneiform osteoarthritic changes

Hallux rigidus is a progressive disorder of the first metatarsophalangeal joint. Starting with a mild limitation of dorsiflexion and little to no discomfort, it can progress to a condition that causes marked limitation of motion at the joint, pain during athletic participation and ultimately pain while walking. Shoes press on the dorsal (top) aspect of the joint and cause pain. Open back shoes and sandals can create discomfort because of the increased motion at the first MTP joint that is caused by those shoes.

Pain in hallux rigidus is caused by the degenerative arthrosis (joint destructive processes, loss of cartilage, bone spur formation, etc.) of the joint. Proliferation of bone and cartilage at the dorsal aspect of the joint contribute to the limitation of movement. Cartilage degeneration and osteophyte formation are caused by abnormal, repetitive contact of the joint surfaces. The sesamoids often are an additional source of pain.

Clinical Presentation:

Patients usually first complain of pain at the dorsal aspect (top) of the joint. Usually, the limited motion is not often noticed at this stage. Later, the head of the metatarsal enlarges dorsally, flattens, and dorsal osteophytes develop. At this stage the available dorsiflexion decreases. Compensatory gait changes follow which include

“... the sesamoid bones are often an additional source of pain..."

increased dorsiflexion at the ankle and increased knee flexion. Athletes change their running gait so that they run more toward the outside of their foot. These compensatory gait changes can lead to other injuries. Central metatarsalgia is often found as weightbearing forces shift laterally. A large dorsal exostosis can cause pain from the pressure of rubbing against footwear. Pain and occasionally hyperkeratoses (hard skin) may develop at the interphalangeal joint in association with compensatory dorsiflexion.

Etiology

Metatarsus primus elevatus (first ray elevation) is believed to be a prime cause of hallux rigidus. Restriction of plantar flexion of the first metatarsal could also play a role. If the first metatarsal head does not functionally contact the supporting surface, the first ray will become elevated or dorsiflex during gait. Conditions which may contribute to metatarsus primus elevatus include gastrocnemius-soleus equinus, functional hypermobility of the first ray, compensated forefoot valgus, and an excessively long first metatarsal. Sesamoid dyscrasias, flexor plate injury or immobility, intrinsic muscle contracture, altered metatarsal head shape, short first metatarsal, long proximal phalanx, or a tight medial slip of the plantar fascia could each contribute to a limitation of plantar flexion of the first metatarsal. (Roukis, Jacobs et al. 2002) (Vanore, Christensen et al. 2003)

Possible Hallux Rigidus Etiologies

Biomechanical
Functional hallux limitus
Functional hypermobility of first ray
Gastrocnemius-soleus equinus
Compensated forefoot valgus
Excessive rearfoot pronation

Post-traumatic
Osteochondral first MTP joint injury
Intra-articular fracture at first MTP
Hallucal sesamoid fracture with resulting sesamoid dysfunction

Structural
Metatarsus primus elevatus
Long first metatarsal
Long proximal phalanx of hallux

Iatrogenic
Post-surgical excessive elevation of the first metatarsal
Post-surgical excessive lengthening of the first metatarsal
Post-surgical malalignment of the first metatarsophalangeal joint
Excessive fibrosis
Hallucal sesamoid dysfunction
Prolonged immobilization

Other
Gouty arthritis
Septic arthritis
Neuromuscular derived muscle imbalance affecting first ray

Treatment

Stage 1, 2 – Functional Orthotics

Most patients with early stage hallux rigidus complain of pain in and around the first MTP. Dorsal pain at the joint is often the primary complaint. The patient doesn’t usually report “stiffness", but the range of motion will usually be limited. Further examination will often find tenderness in one or both hallucal sesamoids. X-ray changes are minimal. Patients with severe symptoms should try a brief course of immobilization followed with off loading the joint using functional orthotics with forefoot modification.

NSAIDS can be useful in the initial stages. Ice is a useful adjunctive therapy. Activity level should be decreased as needed. Steroid injections at the joint will not offer a long term benefit for athletes. If a steroid injection is used the athlete should not participate in sports for 48 hours.

Stages 1 and 2 can often be successfully treated with functional orthotic therapy.

sesamoid accomodation
Tapered sesamoid accomodation


The goal of the functional orthotic is to improve first ray function by enhancing stability and limiting dorsiflexion of the ray. The design of the orthotic should allow the first metatarsal to maximally plantar flex. This allows the first MTP to be in a more relative dorsiflexed position towards the latter stages of stance. Less abnormal motion will take place at the first metatarsophalangeal joint and there will be a less sudden abutment at the dorsal aspect of the joint.

Functional Orthoses Modifications For Hallux Rigidus

Inverted cast correction
Medial heel skive
Deep heel cup
Minimal arch fill on cast

Forefoot modifications:

Reverse Morton’s Padding
Sesamoid Accommodation
Kinetic Wedge (R)
Other techniques to off load the first ray.

Stages 3,4 – Surgical Intervention

Surgical solutions may be needed at Stages 3 and 4 if conservative care fails to relieve pain. The most popular surgical solution for Stage 3 is Chielectomy. In stage 4 arthrodesis of the joint or joint replacement may be required. Conservative therapy can still be useful even at stages 3 and 4.

hallux rigidus, stage 3
Hallux Rigidus - Stage 3

Also see Hallux Rigidus Treatment – Flow Chart in Pribut (2010)

For more information see the references below and Pribut (2010) from which much of this article was adapted.

References

Cotterill, J. (1888). "Stiffness of the great toe in adolescents." Br Med J 1: 1158.
Davies-Colley, M. (1887). "Contraction of the metatarsophalangeal joint of the great toe." Br Med J 1: 728.
Drago, J. J., L. Oloff, et al. (1984). "A comprehensive review of hallux limitus." J Foot Surg 23(3): 213-220.
Dutra, T. (2004) "Inside Insights on Orthotic Modification For Sports" Podiatry Today 17(10) October 2004.
Hanft, J. R., E. T. Mason, et al. (1993). "A new radiographic classification for hallux limitus." J Foot Ankle Surg 32(4): 397-404.
Kravitz, S. R., LaPorta, G. A., Lawton, J. (1994). "Progressive staging classification of hallux limitus and hallux rigidus." Lower Extremity 1(1): 55-66.
Laird, P. O. (1972). "Functional hallux limitus." Illinois Podiatrists 9(4).
Lovejoy, C. O., B. Latimer, et al. (2009). "Combining prehension and propulsion: the foot of Ardipithecus ramidus." Science 326(5949): 72e71-78.
Pribut, S. (2010) "Challenging Running Injuries". Podiatry Management. January, 2010 (in press)
Roukis, T. S., P. M. Jacobs, et al. (2002). "A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus." J Foot Ankle Surg 41(2): 76-95.
Vanore, J. V., J. C. Christensen, et al. (2003). "Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: Hallux rigidus." J Foot Ankle Surg 42(3): 124-136.

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Copyright 2003-2009 Stephen M. Pribut