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Hallux rigidus means 'stiff great toe' and was first described in the orthopaedic literature towards the end of the nineteenth century. The degenerative changes can be mild to severe, as can the consequent disability. It affects adults and adolescents and there may or may not be a history of trauma.
The aetiology is unknown. It is thought to relate to 'wear and tear' of the joint through acute, or more usually, chronic repetitive injury. Symptoms result from a degenerative arthropathy of the first metatarsophalangeal (MTP) joint. These degenerative changes are characterised by:
- Loss of cartilage
- Altered joint mechanics
Pain and loss of function result from dorsal osteophytes, inflammation and irregularity of joint articular surfaces. As with any degenerative arthropathy the combination of overuse, injury or abnormal joint mechanics may combine to produce stresses and damage to articular cartilage.
- Hallux rigidus is one of the most common causes of forefoot pain.
- Most studies report a higher incidence in men.
- Most cases (80%) are bilateral and, of these, nearly all have a family history.
- Male, middle-aged.
- Active (runners).
- Bilateral and familial.
- Worse with certain activities and particular footwear.
- Localised on the dorsal surface of the great toe.
- More diffuse pain in the lateral forefoot (caused by compensatory gait).
- Dysaesthesia caused by compression of the dorsomedial cutaneous nerve (footwear with osteophyte).
- Late diffuse pain of advanced degenerative disease.
- A less common complaint.
- It occurs most often in the adolescent group (complaining of rigid first toe).
- Osteophytic swelling to the dorsum of the first MTP joint.
- Limited first MTP dorsiflexion and plantar flexion (with pain as well).
- Pain and crepitus in late presentation.
- May be affected.
- Markedly limited dorsiflexion at toe-off.
- May be antalgic.
Plain X-ray reveals the radiographic features of the degenerative changes (see 'Staging', below):
- Joint space narrowing
- Joint irregularities
- Bone cysts
One study of 110 patients showed an association between:
- Hallux rigidus and hallux valgus interphalangeus
- Family history of hallux rigidus and bilateral hallux rigidus
- Trauma and hallux rigidus (unilateral cases)
There was no association between hallux rigidus and:
- Pes planus
- Length of the first metatarsal
- Hallux valgus
- Metatarsus adductus
Often classified as:
- Mild - maintained joint space, minimal changes
- Moderate - some narrowing, cysts and sclerosis
- Severe - severe changes with loose bodies
A classification was proposed in 1999 which incorporated radiographic features.
- Grade 0:
- Dorsiflexion 40-60°
- Normal radiography
- No pain
- Grade 1
- Dorsiflexion 30-40°
- Dorsal osteophytes
- Minimal/no other joint changes
- Grade 2
- Dorsiflexion 10-30°
- Mild-to-moderate joint narrowing or sclerosis
- Grade 3
- Dorsiflexion less than 10°
- Severe radiographic changes
- Constant moderate-to-severe pain at extremities
- Grade 4
- Stiff joint
- Severe changes with loose bodies and osteochondritis dissecans
- Pain through the entire range of movement
Non-surgical or conservative approaches
- Can be used for various stages of disease.
- Analgesics including non-steroidal anti-inflammatory drugs may be helpful.
- Orthotics limiting extreme dorsiflexion are helpful.
- Modification of activities (for example, avoid kneeling/squatting).
- Manipulation and injection (for grades 1 and 2 only).
- Choice depends on:
- Stage of involvement.
- Degree of limitation of the range of movement.
- Activity levels of the patient.
- Preference of the surgeon and the patient.
- Joint sparing procedures such as dorsal cheilectomy:
- Cheilectomy for treatment of hallux rigidus relieves dorsal impingement (usually the source of pain). It is recommended for mild-to-moderate deformity.
- With or without proximal phalangeal osteotomy
- Excision arthroplasty or Keller procedure:
- MTP arthrodesis:
- Metallic resurfacing of the metatarsal side of the MTP joint has shown promising results.
- Not yet recommended.
- High complication rate.
These depend on the particular treatment used.
This again depends on the severity, patient activity and expectation as well as the particular treatment used. Generally speaking, operative treatments are offered to patients refractory to non-operative treatments.
Further reading & references
- Beeson P, Phillips C, Corr S, et al; Classification systems for hallux rigidus: a review of the literature. Foot Ankle Int. 2008 Apr;29(4):407-14. doi: 10.3113/FAI.2008.0407.
- Coughlin MJ, Shurnas PS; Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2003 Oct;24(10):731-43.
- Solan MC, Calder JD, Bendall SP; Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg Br. 2001 Jul;83(5):706-8.
- Coughlin MJ, Shurnas PS; Hallux rigidus. J Bone Joint Surg Am. 2004 Sep;86-A Suppl 1(Pt 2):119-30.
- Beertema W, Draijer WF, van Os JJ, et al; A retrospective analysis of surgical treatment in patients with symptomatic hallux rigidus: long-term follow-up. J Foot Ankle Surg. 2006 Jul-Aug;45(4):244-51.
- Hallux Rigidus and Cheilectomy; Wheeless' Textbook of Orthopaedics
- Machacek F Jr, Easley ME, Gruber F, et al; Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am. 2004 Jun;86-A(6):1131-8.
- Kline AJ, Hasselman CT; Metatarsal head resurfacing for advanced hallux rigidus. Foot Ankle Int. 2013 May;34(5):716-25. doi: 10.1177/1071100713478930. Epub 2013 Feb 13.
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Dr Richard Draper
Dr Colin Tidy
Dr John Cox