Hallux Rigidus

Updated: May 01, 2017
  • Author: Minoo Hadjari Hollis, MD; Chief Editor: Anthony E Johnson, MD, FAOA, FACS  more...
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Overview

Background

Hallux rigidus literally means "stiff great toe"; however, limitation of great-toe motion is only one 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, though many patients present without such a history.

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 remains the most common term used to describe the condition in the orthopedic literature. [2, 3]

Hallux rigidus is a syndrome with symptoms related to degeneration of the first MTP joint. The symptoms result from cartilage wear, altered joint mechanics, and osteophyte formation, particularly on the dorsal aspect of the first MT head. The pain in hallux rigidus usually derives from impingement of dorsal osteophytes, from shoe-related pressure on prominent osteophytes, or both. Irregularity of the articular cartilage surface(s) can result in pain at the extrmes of motion with activity.

Nonsurgical treatment measures are often successful, regardless of the severity of hallux rigidus. [4] In cases where the condition is refractory to appropriate nonoperative treatment methods, the operative options are myriad, and the choice should be determined primarily on the basis of the severity of the degenerative joint disease (DJD).

Future advances in addressing hallux rigidus will likely include, through improvements of arthroscopic methods, [5] earlier diagnosis and treatment of lesions involving the symptomatic MTP joint. Early debridement, biologic resurfacing, and the establishment of fuller range of motion (ROM) may improve the longevity of this joint and minimize the need for joint-destructive salvage methods.

The future development of joint arthroplasty implants and methods may allow joint replacement to be considered as a reliable primary procedure for treatment of severe degenerative arthritis of the great-toe MTP joint. [6, 7, 8]

For patient education resources, see Osteoarthritis and Repetitive Motion Injuries.

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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 et al used a magnetic tracking system to monitor the three-dimensional movement of the proximal phalanx while the toe position was changed from a neutral position to full extension. [9] 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. [10]

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.

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Etiology

The true etiology of hallux rigidus is not known. Most commonly, hallux rigidus is thought to be caused by chronic overuse of the first MTP joint. Multiple theories have been proposed for the underlying etiology.

Some authors have associated hallux rigidus with athletic activities involving running [11] ; 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 suggested traumatic injury to the articular cartilage—either acute trauma (as in turf toe) or chronic, repetitive, minor injury—as the underlying mechanism.

Clanton et al 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 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. [12] 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. [13]

Lambrinudi proposed the so-called metatarsus primus elevatus, in 1938. [14] 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). [15] 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. [16]

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. [17]

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 et al suggested that the disease proceeds in stages from adolescence through adulthood. [16] Vilaseca et al 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. [18] 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. [19]

An abnormally long first MT (index-plus foot) increases the first MTP joint stress during toe-off, as proposed by Nilsonne in 1930. [20] This predisposes an individual to hallux rigidus. Nilsonne et al [21] 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 et al examined possible associations between the disorder and various physical, health, and lifestyle factors. [22] 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.

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Epidemiology

Hallux rigidus is the second most common disorder of the first MTP joint, after hallux valgus.

Coughlin and Shurnas reported findings in 110 patients who had undergone surgery for hallux rigidus. [22] 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.

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Prognosis

Nonsurgical measures can often be used to successfully treat patients with varying degrees of severity of hallux rigidus. In patients in whom the condition is refractory to nonoperative treatment methods, the operative options depend on the severity of the DJD.

Waizy et al analyzed long-term clinical outcome and patient satisfaction in 60 patients (20 grade I, 35 grade II, and 5 grade III) with symptomatic hallux rigidus who received joint-preserving operative care. [23]  At follow-up, mean dorsiflexion (DF) increased to about 21.7º in grade I patients, about 23.7º in grade II, and about 26.3º in grade III. At first follow-up, 100% of grade I patients had only occasional pain or no pain at all, compared with 63.3% of grade II and 75% of grade III. At second follow-up, 77.8% of grade I and 73.9% of grade II patients had no pain. Four patients had persistent hypoesthesia of the medial side of the great toe, and three patients had delayed wound healing. No patietns required revisions or further surgical procedures.

Tagoe et al followed 33 patients who had undergone total sesamoidectomy for hallux rigidus/limitus (36 procedures) for 2-4 years. [24] According to the authors, there were high levels of clinical improvement and patient satisfaction following the procedure, with no significant functional impairment or malalignment. There were no instances of pain on metatarsal compression or of transfer metatarsalgia. The authors concluded that for symptomatic patients in whom a joint replacement/fusion is not indicated, total sesamoidectomy may be beneficial as an interim procedure for joints with a moderate degree of arthrosis (grade II to II).

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