Hallux Rigidus

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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 may include earlier diagnosis and treatment of lesions involving the symptomatic MTP joint, likely through improvements of arthroscopic methods. [5]   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.

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.

The true etiology of hallux rigidus is not known. Most commonly, hallux rigidus is thought to be caused by chronic overuse or unfavorable use 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 seven 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]

In 1938, Lambrinudi proposed the so-called metatarsus primus elevatus. [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, 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, and that this restriction of motion accelerates the degenerative process. Others have proposed that flattening of the head is a secondary result. [17]

Some authors have proposed 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.

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.

Nonsurgical measures can often be used to successfully treat patients with varying degrees of severity of hallux rigidus. For 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 1, 35 grade 2, 5 grade 3) with symptomatic hallux rigidus who received joint-preserving operative care. [23]  At follow-up, mean dorsiflexion increased to about 21.7º in grade 1 patients, 23.7º in grade 2, and 26.3º in grade 3. At first follow-up, 100% of grade 1 patients had only occasional pain or no pain at all, compared with 63.3% of grade 2 and 75% of grade 3. At second follow-up, 77.8% of grade 1 and 73.9% of grade 2 patients had no pain. Four patients had persistent hypoesthesia of the medial side of the great toe, and three had delayed wound healing. No patients required revisions or further surgical procedures.

Tagoe et al followed patients who underwent total sesamoidectomy for hallux rigidus/limitus (N = 33; 36 procedures) for 2-4 years. [24] They reported high levels of clinical improvement and patient satisfaction after the procedure, with no significant functional impairment or malalignment and no instances of pain on metatarsal compression or of transfer metatarsalgia. The authors concluded that for symptomatic patients in whom joint replacement/fusion is not indicated, total sesamoidectomy may be beneficial as an interim procedure for joints with a moderate degree of arthrosis (grade 2-3).

Mann et al reported on 20 patients who were treated with cheilectomy and monitored for an average of 67.6 months. [25]  They stated that patient satisfaction with the procedure was uniform and that they had an 85% success rate, with an average DF of 30° after surgery.

Mann and Clanton reported on 34 cheilectomies, with 74% improvement in motion, an average of 20° improvement in joint motion, and 90% pain relief, with an average resultant DF of 48°. [17]  Over an average follow-up period of 56 months, they reported no complications.

Easley et al reported on 75 feet treated with cheilectomy, with an average follow-up of 63 months. [26]  The average DF improved by 20°, but nine of 21 patients with recurrent dorsal formation were symptomatic.

Mulier et al followed up 22 athletes who had undergone cheilectomy for grade 1 or 2 hallux rigidus and noted that functional results were excellent in 14 of the athletes, good in seven, and fair in one at 5-year follow-up. [27]  Seven patients had radiographic signs of progression at follow-up.

Mackay et al evaluated 39 patients at a mean follow-up time of 3.8 years after cheilectomy. [28]  The patients had grade 1, 2, or 3 hallux rigidus as defined by the Regnauld classification. The investigators noted significant improvements in pain, activity level, tiptoe walking ability, and ROM among patients no matter which grade of hallux rigidus had been treated. Footwear selection improved significantly in patients with grade 1 or 2 hallux rigidus but not in patients with grade 3.

Nicolosi et al performed a retrospective study of 58 patients (mean age, 55.71 ± 9.51 years) to evaluate the long-term efficacy (mean follow-up, 7.14 years; range, 39 weeks to 14.87 years) of aggressive cheilectomy for addressing degenerative joint disease (DJD) of the first MTP joint. [29]  In all, 51 of the 58 patients had no limitations in their daily activities; only two subsequently required arthrodesis.

Thomas and Smith reviewed 24 great toes after proximal phalanx osteotomy and reported improvement in all patients. [30]  Recovery time was 2-12 months. The average increase in DF was 7°, and PF increased 3°. The increase in PF was attributed to aggressive physical therapy. Radiographically, the dorsal MTP joint space increased, and the length of the proximal phalanx decreased by an average of 4 mm. The resting position of the toe showed an average increase in elevation of 5.4 mm.

Citron and Neil reported on 10 toes at a 22-year follow-up. [31]  All patients experienced complete pain relief shortly after the osteotomy, and relief was permanent in five of the 10 toes. One patient required an MTP fusion. The researchers found that after the osteotomy, PF of the MTP joint was lost, but the arc of movement of the interphalangeal (IP) joint was shifted toward PF.

van Dijk et al performed a prospective study in 24 consecutive patients, 17 of whom were high-level athletes. In the dorsal impingement group, eight of 12 patients had a good or excellent result after a minimum follow-up of 2 years. [32]  One patient in this group had a persistent loss of sensitivity of the hallux.

Iqbal et al evaluated 15 patients who underwent arthroscopic cheilectomy for hallux rigidus and reported encouraging early results without the need for revision surgery. [33]

Despite the number of first-MT osteotomies for hallux rigidus that have been reported in the literature, no long-term results from these procedures are available. In addition, the high rates of complications, such as nonunion, malunion, intractable plantar ketosis under the first MT head, sesamoiditis, transfer lesions, stress fractures, dorsal contractures, arthrofibrosis, and progressive DJD, make the results of these procedures unpredictable. The associated high risks and the minimal potential benefits in most patients with hallux rigidus must be considered. [34, 35]

Coughlin et al reported a 92% fusion rate with the use of congruent cup-shaped reamers and a dorsal plate (as performed on 58 feet). [36]  They described a 98% fusion rate, and 93% of their cases had good or excellent results. Plate removal was necessary in four cases, and they reported delayed union in one case and plate breakage in one case.

Chana et al reported the use of suture stabilization using size 00 chromic catgut postoperative casting to achieve stable arthrodesis in 87 of 87 feet. They reported a 10% incidence of pseudoarthrosis and four malunions.

In 1993, Curtis et al compared the biomechanical results of four methods of internal fixation and noted that bony preparation with power conical reamers and supplementary interfragmentary screw fixation had the most stable results. [37]

Coughlin et al reported on 16 feet that underwent arthrodesis after the failure of a Keller procedure. [38]  Using multiple intramedullary threaded Steinmann pins to fix the bone, the authors noted a 100% arthrodesis rate. They used interposition of an iliac crest bone graft in four feet with an excessively short hallux. In 92% of cases, intractable keratosis was relieved; the characteristic deformity of the hallux was improved.

Smith et al, using five threaded 0.062 Kirschner wires (K-wires) for fixation in 34 feet after the joint surfaces had been prepared with conical reamers, reported an arthrodesis rate of 97%. [39]

Hamilton et al reported on 37 feet after resection arthroplasty with the extensor hood and extensor brevis reattached to the flexor hallucis brevis (FHB) as a capsular interposition arthroplasty (with minimal bone resection). [40]  They found maintenance of PF strength in four of five cases, with an average of 50° DF.

Kennedy et al reported on a peg-in-socket method for the salvage of failed Keller excisional arthroplasty in the presence of poor bone stock. [41]

DeFrino et al evaluated plantar pressure distribution and gait patterns after first MTP arthrodesis. [42]  They reported the restoration of the weightbearing function of the first ray, with greater maximum force carried by the distal hallux at toe-off. The authors noted a significantly shorter step length, with some loss in ankle PF at toe-off on the fused side. They suggested a reduction in ankle torque and ankle power at pushoff. The authors also reported a high level of patient satisfaction with this procedure.

Excisional/interposition arthroplasty

Lau et al retrospectively reviewed 11 feet with grade 3 osteoarthritis that were treated with interposition arthroplasty and 24 feet with grade 2 osteoarthritis that were treated with cheilectomy. [43]  Approximately 2 years after treatment, results were compared with respect to postoperative motion, visual analogue pain scale scores, and Medical Outcomes Study 36-item short-form (SF-36) results. About 73% of patients who underwent interposition arthroplasty reported weakness, compared with 17% of the group that underwent cheilectomy. About 73% of patients in the former group reported satisfaction with interposition arthroplasty, and about 88% in the latter group were satisfied with cheilectomy.

Significant improvement of pain and function and an average DF of 50° can be achieved, as reported by Hamilton et al. [40]  Relative contraindications for interposition arthroplasty for the treatment of hallux rigidus include relatively short first MTs (Morton or Grecian foot) owing to the development of transfer lesions and, for high-level athletes and ballet dancers, because of the loss of the windlass mechanism.

Silicone arthroplasty

Rahman et al reviewed 78 feet after silicone hemiarthroplasty of the first MTP joint. [44]  At a mean follow-up of 4.5 years, 56 feet showed radiologic evidence that was suggestive of silicone granulomatous disease, with three cases of the disease being confirmed at histologic study. The investigators suggested that this operation be abandoned.

Shankar reported on 40 cases of hallux rigidus that were treated with silicone hemiarthroplasty and then followed up for an average of 110 months. [45]  The author stated that 36% of the study’s patients were unhappy with the results of the procedure and that six implants had to be removed because of pain and fragmentation.

Metallic arthroplasty

Townley et al conducted a long-term retrospective study of 279 nonconstrained metallic resurfacing implants used for hemiarthroplasty. [46]  Among the cases, 95.3% had good or excellent results with a follow-up time of 10 months to 33 years.

Johnson et al reported results achieved with a stainless steel and polyethylene surface replacement prosthesis for the first MTP joint, fixed with methylmethacrylate. [47]  In a series of 21 joints, the satisfaction rate was 81% at an average follow-up of 43 months.

Lu et al reported findings from an 8-year follow-up study of 14 cases with a titanium total joint prosthesis. [48]  They reported a 31.8% complication rate and a 27.3% rate of revision.

Gheorgiu et al retrospectively reviewed data from 11 patients (12 feet) who underwent first MTP joint hemiarthroplasty with the HemiCAP (Arthrosurface, Franklin, MA) prosthesis (mean follow-up, 47 months; range, 36-48 months). [8]  Of the 12 feet, 41.7% were pain-free at follow-up, 25% had mild pain, 16.7% had moderate pain, and 16.7% had severe pain. In addition, 42% showed no evidence of radiologic subsidence, and 58% showed a mean subsidence of 2.71 mm (range, 1-6 mm). Most of the patients continued to have a limited ROM, reporting only reasonable levels of satisfaction.

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Minoo Hadjari Hollis, MD Orthopedic Surgeon, Sound Orthopedics and Foot and Ankle Center

Minoo Hadjari Hollis, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas C Dowd, MD Associate Director of Orthopedic Surgery Residency Program, Department of Orthopedic Surgery, San Antonio Military Medical Center; Assistant Professor of Surgery, The Norman M Rich Department of Surgery, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Thomas C Dowd, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Society of Military Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AOFAS; JBJS; AOA; AAOS.

John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

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