Hallux Rigidus

Other Names

This page refers to Hallux Rigidus, a degenerative joint condition of the First Metatarsophalangeal Joint (MTPJ)
A most common form of arthritis in the foot
Nearly 10% of adults have symptomatic hallux rigidus^[2]
- Radiographic evidence is present in 20% to 48% of adults older than 40 years

General
- The degenerative joint disease of the 1st MTP is characterized by pain, stiffness

General
- Primarily considered an idiopathic disease with multiple risk factors
- The underlying cause is typically multifactorial
History of trauma
- Individuals that have repetitive microtrauma to the foot
- Single acute event
- Hyperextension injuries to the plantar plate
Biomechanical factors
- Metarsus primus elevatus
- Hallux valgus
- First ray hypermobility
- Metatarsus adductus
Non-contributatory
- Achilles contracture
- Shoe wear
- Elevated metatarsal head

1st Metatarsophalangeal Joint (MTPJ)
- Articulation of the first metatarsal and base of the proximal phalanx, sesamoids
- Stabilized by the joint capsule, medial and collateral ligaments, crossing musculotendinous units

Demographic
- Family History
  - 2/3 of patients have a positive family history
  - 95% of patients with a family history had bilateral symptoms
- Women
Sports
- Soccer
- Runners
- Ballet

Fractures & Osseous Disease
- Traumatic/ Acute
  - Talus Fracture
  - Calcaneus Fracture
  - Traumatic Navicular Fracture
  - Cuboid Fracture
  - Cuneiform Fracture
  - Metatarsal Fracture
    - Fifth Metatarsal Fracture
  - Toe Fracture
  - Hallux Sesamoid Fracture
- Stress Fractures
  - Navicular Stress Fracture
  - Metatarsal Stress Fracture
- Other Osseous
  - Tarsal Coalition
  - Accessory Navicular Syndrome
Dislocations & Subluxations
- Toe Dislocation
- Lisfranc Injury
- Chopart Complex Injury
- Cuboid Syndrome
Muscle and Tendon Injuries
- Posterior Tibial Tendon Dysfunction
- Peroneal Tendonitis
- Tibialis Anterior Tendinopathy
- Flexor Hallucis Longus Tendinopathy
Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
Toenail
- Subungual Hematoma
- Subungual Exostosis
- Nail Bed Laceration
- Onychocryptosis (Ingrown Toenail)
- Onychodystrophy
- Paronychia
- Onychomycosis
Pediatrics
- Fifth Metatarsal Apophysitis (Iselin’s Disease)
- Calcaneal Apophysitis (Sever’s Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)

Radiograph of the foot showing joint space narrowing, subchondral sclerosis, and dorsal osteophyte formation of the 1st MTPJ^[8]

History
- Pain at the first metatarsophalangeal joint, especially while walking or with push-off
- Pain is typically worse dorsally
- Swelling, dorsal osteophytes, and soft tissue prominence
- Decreased range of motion, stiffness
- Pain while wearing tight shoes
- Pain after standing for prolonged periods
- When walking, symptoms are most severe at terminal heel-rise just before toe-off
- Pain after loading 1st MTPJ such as tip-toeing, running, stairs, push ups^[9]
- Antalgic gait or limp is often present
- Lateral foot pain may develop due to altered gait and walking on a lateral foot
- Neuropathic pain from compression of the dorsomedial branch of the superficial peroneal nerve^[10]
- Chronically, the joint may ankylose naturally and eventually become painless
Physical Exam: Physical Exam Foot
- Swollen inflamed the first MTPJ
- Tender osteophytes on the dorsal surface
- Limited range of motion
- Pain in dorsiflexion (due to dorsal osteophyte impingement)^[11]
- Pain in plantarflexion (stretching of the dorsal capsule over the dorsal osteophyte)
- Decreased push-off strength
- Compare to unaffected foot if symptoms unilateral
Special Tests
- MTPJ Grind Test
- Tinsel Test may indicate compression of the dorsomedial branch of the superficial peroneal nerve

Standard Radiographs Foot
- Standard weight-bearing 3 views
Findings on the lateral view
- Dorsal osteophytes
- Joint space narrowing
Findings on AP view
- Subchondral sclerosis
- Subchondral cysts
- Flattening of the metatarsal head
- Joint space narrowing

Grade	Dorsiflexion	Radiographic findings	Clinical findings
0	40-60° and/or 10-20% compared to another side	Normal	No pain; only stiffness and loss of motion on examination
1	30-40° and/or 20-50% loss compared to another side	Dorsal osteophyte is the main finding, minimal joint-space narrowing, minimal peri-articular sclerosis, minimal flattening of the metatarsal head	Mild or occasional pain and stiffness, pain at extremes of dorsiflexion and/or plantar flexion on examination
2	10-30° and/or 50-75% loss compared to another side	Dorsal, lateral and possible medial osteophytes giving a flattened appearance to metatarsal head, no more than of dorsal joint space involved on lateral radiograph, mild-to-moderate joint space narrowing and sclerosis, sesamoids not usually involved	Moderate to severe pain and stiffness that may be constant; pain occurs just before maximum dorsiflexion and maximum plantar flexion on examination
3	<10° and/or 75-100% loss compared to another side. There is a notable loss of plantar flexion as well.	Same as in grade 2 but with substantial narrowing, possibly with periarticular cystic changes, more than of dorsal joint space involved on lateral radiograph, sesamoids enlarged and/or cystic and/or irregular	Nearly constant pain and substantial stiffness at extremes of range of motion but not at midrange
4	Same as in grade 3	Same as in grade 3	Same criteria as in grade 3 BUT there is definite pain in mid-range of passive motion

Indications
- Vast majority of cases
Ice
Analgesics
- NSAIDS
- Acetaminophen
Shoe Modification
- Optimal shoe has deep toe box (decrease contact on dorsal osteophytes), stiff sole with limited movement of 1st MTPJ
- Shoe rocker sole may decrease movement by causing a rolling transition between heel-strike and toe-off.
- Wide toe shoe
- Avoid high heels
Orthotics
- Goal: stiffen shoe, limit dorsiflexion of 1st MTPJ^[12]
- Footplate made of spring-steel or carbon fibre
- Extended shank
- Morton’s Extension: limits movement at the hallux, better tolerated by active patients
Activity modification
- Avoidance of activities that cause repetitive dorsiflexion of the first MTP
- This includes running, jumping, and traveling upstairs
Corticosteroid Injection
- Commonly used, likely beneficial with less severe arthritis
- When combined with manipulation under anesthesia, appears to help relieve symptoms and delay surgery in grade 1 and 2 disease, but not grade 3/4^[13]
Hyaluronic Acid
- RCT of 151 patients failed to show any reduction in pain at 3 months compared to placebo^[14]