eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Hallux Rigidus

Author: Minoo Hadjari Hollis, MD, Consulting Surgeon, Department of Surgery, Gulf Breeze Hospital
Contributor Information and Disclosures

Updated: Sep 14, 2007

Introduction

Hallux rigidus literally means "stiff great toe"; however, limitation of big toe motion is only 1 element of the range of symptoms that constitute the diagnosis of hallux rigidus. Hallux rigidus encompasses mild to severe degenerative arthritis of the first metatarsophalangeal (MTP) joint of the foot. Symptoms can range from mild to disabling. The condition, which occurs in adolescents and adults, can be associated with a history of previous trauma, although many patients present without such a history.

History of the Procedure

This condition was initially described in 1887 by Davies-Colley, who defined hallux flexus as a plantarflexed posture of phalanx relative to the metatarsal (MT) head.¹ About the same time, Cotterill used the term hallux rigidus, which is the most common term used to describe the condition in the orthopedic literature.^2,3

Problem

Hallux rigidus is a syndrome with symptoms that are related to degenerative arthritis of the great-toe MTP joint. The symptoms result from cartilage wear, altered joint mechanics, and osteophyte formation, particularly on the dorsal aspect of the first MT head. Hallux rigidus usually causes pain from impingement of dorsal osteophytes, from inflammation, and from shoe-related pressure on prominent osteophytes. It also causes range-of-motion (ROM) pain related to the irregularity of the articular cartilage surface. This condition is seen in 2 distinct populations: persons who present in adolescence and those who present in adulthood.

Frequency

Hallux rigidus is the second most common disorder of the first MTP joint (with the most common being hallux valgus).

In 2003, after a mean follow-up period of 9 years, Coughlin and Shurnas reported their findings in 110 patients who had undergone surgery for hallux rigidus.⁴  The authors noted that on final evaluation, about 80% of the patients showed bilateral involvement. In the bilateral cases, 98% of the patients had a positive family history. Although 62% of the patients in Coughlin and Shurnas's report were women, other investigators have reported a slight male predominance.

Etiology

The true etiology of hallux rigidus is not known. Most commonly, hallux rigidus is thought to be caused by wear and tear on the first MTP joint. Multiple theories have been proposed for the underlying etiology of this condition. Some authors have associated hallux rigidus with athletic activities involving running; in this case, the disorder possibly results from repetitive hyperextension of the first MTP joint with chronic gradual attenuation of the plantar plate and subsequent instability. Hallux rigidus has also been seen as a long-term sequela of acute injuries to the great-toe MTP joint, such as turf toe. Several authors have proposed that traumatic injury to the articular cartilage — either acute trauma (as in turf toe) or chronic, repetitive, minor injury — is the underlying mechanism.

Clanton and colleagues found hallux valgus and early hallux rigidus to be long-term sequelae. After more than 5 years of follow-up, Clanton and Seifert found that among 20 athletes with previous turf-toe injury, half suffered from persistent symptoms. The long-term effects of turf-toe require further study.

In 1933, Kingreen reported that osteochondritis dissecans (OCD) led to development of hallux rigidus. Goodfellow proposed that the development of an osteochondrosis in childhood creates a defect and secondary slow-remodeling collapse, leading to abnormal motion in the forefoot.⁵ McMaster reported on 7 adolescent patients who had an articular defect of approximately 5 mm located directly beneath the dorsal lip of the proximal phalanx; this defect was associated with symptoms of hallux rigidus.⁶

Lambrinudi proposed the so-called metatarsus primus elevatus, in 1938.⁷ Theoretically, an abnormally elevated first MT causes excessive flexion of the great toe during gait and subsequent development of flexion contracture at the first MTP joint. These abnormal mechanics cause hallux rigidus. Others, such as Jack, in 1940, postulated that with the elevated first MT, increased overload of the second MT occurs, with compensatory contracture of the flexor hallucis brevis (FHB).⁸ This contracture pulls the proximal phalanx inferiorly, driving its dorsal rim into the MT head and leading to localized degenerative changes in the articular cartilage. Hypermobility of the first ray leading to flexor spasm and impingement of the proximal phalanx on the MT head is another proposed theory.⁹ Yet other researchers, such as Jansed, in 1920, have implicated flatfoot. All of these theories are without true scientific data.

In 1986, Mann first theorized that a flat first MT head restricts, to a relative extent, the medial and lateral motion of the first MTP joint, creating increased stress in the sagittal plane. This restriction of motion, he said, accelerates the degenerative process. Others have proposed that flattening of the head is a secondary result.

Some authors propose that the disease may develop somewhat differently in adolescents than in adults. The observation that the first MTP joint returns to normal under anesthesia in adolescents suggests that anatomic anomalies and spasm may be contributing factors.

Bingold and Collins believe that the disease proceeds in stages from adolescence through adulthood.⁹ Vilaseca and Ribes found that a distal physis of the first MT head is present in 75% of children's feet and is visible in children aged 2-11 years.¹⁰ They also found that the first MT is longer than the second in children who have had a longer persistence of this distal physis. Therefore, individual anatomic variations may play a role in causing functional changes in the MTP motion and position during gait.

An abnormally long first MT (index-plus foot) increases the first MTP joint stress during toe-off, as proposed by Nilsonne in 1930.¹¹ This predisposes an individual to hallux rigidus. Nilsonne, Bonney, and Mercian suggested that the excessively long toe requires a longer shoe, which in turn requires constant contraction of the great toe flexors to grip the shoe while the person is walking. This gripping can lead to inflammation and secondary spasm, therefore limiting motion at the MTP joint at the great toe.

In a study involving 110 patients with hallux rigidus, Coughlin and Shurnas examined possible associations between the disorder and various physical, health, and lifestyle factors.⁴ The authors saw no association between hallux rigidus and pes planus, first MT length, metatarsus primus elevatus, first-ray hypermobility, hallux valgus, footwear, occupation, obesity, or metatarsus adductus. However, they did see an association between hallux rigidus and hallux valgus interphalangeus (mean 18°), family history (in bilateral cases of hallux rigidus), and trauma (in unilateral cases of the condition). No specific distinction was made between adolescent and adult patients.

Pathophysiology

The pathophysiology of hallux rigidus is similar to that of degenerative arthritis in any joint. Overuse, injury, or abnormal joint mechanics lead to abnormal stresses on the articular cartilage. In an in vitro study, Ahn and colleagues used a magnetic tracking system to monitor the 3-dimensional movement of the proximal phalanx while the toe position was changed from a neutral position to full extension.¹² The contact distribution shifted dorsally with increasing degrees of extension. These data are consistent with the observation that chondral erosions associated with hallux rigidus and degenerative arthritis initially affect the dorsal articular surface of the MT.

Articular degenerative changes are associated with dehydration of the cartilage, which, in turn, is more susceptible to injury resulting from shear and compressive forces. The subchondral bone shares these stresses, which subsequently lead to increased subchondral bone density, formation of periarticular osteophytes, and, in severe cases, cystic changes. The osteophytes limit first MTP joint motion and further compromise the normal mechanics of this joint. This effect can accelerate the degenerative process. In severe cases, the articular cartilage is completely denuded.

Presentation

The most typical presentation is pain on the top of the great toe in an active, middle-aged individual. In addition, patients may also complain of diffuse, lateral forefoot pain resulting from increased weight bearing on the lateral foot to offload the hallux. The pain is worse with certain activities and with certain shoes. Hallux rigidus has been associated with a history of athletic activities involving running. Whether running is a true cause of the disorder or a factor that aggravates the symptoms is not known.

Dysesthesia along the dorsomedial hallux occasionally occurs as a result of compression by shoes or stretching of the dorsomedial cutaneous nerve. Complaints of stiffness and motion loss are not common, except in adolescents, who often present with complaints of a rigid first MTP joint. Dorsal pain caused by external pressure over a prominent osteophyte frequently accompanies other presentations. Diffuse arthritic pain usually occurs late and is associated with more severe degenerative changes.

At physical examination, the presence of a tender dorsal osteophyte at the first MTP joint usually confirms the diagnosis of hallux rigidus. First MTP dorsiflexion (DF) is limited by periarticular osteophytes, and pain often occurs at maximum DF. Dorsal pain with maximum plantarflexion (PF) is common and likely represents irritation of the extensor hallucis longus (EHL) as it passes over the dorsal osteophyte. Pain and crepitus that occur throughout the entire ROM indicate late-stage degenerative arthritis of the first MTP joint. The patient's gait may be slightly antalgic, and limitation of MTP joint DF at toe-off may be noted.

Classification

• In 1988, Hattrup and Johnson described the following radiographic classification system:
  • Grade 1 - Mild changes with a maintained joint space and minimal spurring
  • Grade 2 - Moderate changes, joint-space narrowing, bony proliferation on the MT head, and phalanx and subchondral sclerosis or cysts
  • Grade 3 - Severe changes with significant joint-space narrowing, extensive bony proliferation, and loose bodies or a dorsal ossicle
• In 1999, Coughlin and Shurnas proposed a classification system based on ROM, as well as on radiographic and examination findings, as follows⁴ :
  • Grade 0 - DF of 40-60° (20% loss of normal motion), normal radiographic results, and no pain
  • Grade 1 - DF of 30-40°, dorsal osteophytes, and minimal to no other joint changes
  • Grade 2 - DF of 10-30°, mild flattening of the MTP joint, mild to moderate joint narrowing or sclerosis, and dorsal, lateral, and/or medial osteophytes
  • Grade 3 - DF of less than 10°, often less than 10° PF, severe radiographic changes with hypertrophied cysts or erosions or with irregular sesamoids, constant moderate to severe pain, and pain at the extremes of the ROM
  • Grade 4 - Stiff joint, radiographs showing loose bodies or OCD, and pain throughout the entire ROM

Indications

Nonsurgical techniques can often be used to successfully treat patients with varying degrees of severity of hallux rigidus. However, when the condition is refractory to nonoperative treatment methods, a number of operations that have been described can be employed as treatment. The choice of operation depends on the degree of involvement, the ROM limitations, the individual's activity level, and the surgeon's and patient's preference. Options include joint-sparing procedures, such as cheilectomy, with or without proximal phalanx osteotomy (the Moberg procedure), as well as MT osteotomy, joint arthroplasty, and arthrodesis.

Dorsal cheilectomy is indicated in patients with mild to moderate arthritic changes with less than 50% involvement of the joint surface. A proximal phalangeal osteotomy can be added in patients in whom sufficient DF is not obtained (if PF is sufficient).

Excisional arthroplasty, or the Keller procedure, is associated with a number of potential complications and is not generally recommended. Capsular interposition arthroplasty, however, can provide good pain relief in select individuals with advanced degenerative disease.

MTP arthrodesis is an excellent procedure that is indicated in most cases of advanced hallux rigidus. The benefits of MT osteotomies are theoretical, and these procedures are not recommended for the treatment of uncomplicated hallux rigidus.

Silicone-implant arthroplasty probably has no place in the treatment of hallux rigidus. Current metallic hemiarthroplasty and total arthroplasty do not seem to offer significant benefit compared with capsular interposition arthroplasty, and the techniques have many reported complications.

Relevant Anatomy

See Surgical Therapy.

Contraindications

An absolute contraindication for operative treatment is poor peripheral circulation.

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