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Hallux Limitus and Hallux Rigidus

Hallux Limitus/rigidus are varying degrees of arthritis that affects the great toe joint. It results from wear and tear on the joint surface over time. The condition may follow an injury to the joint or, in some cases, may develop without injury but because of the way one walks all their life.

The joint at the base of the great toe is called the metatarsophalangeal joint and connects the first metatarsal and the great toe which is called the hallux. The joint is covered with cartilage and looks like the surface of the chicken leg (white, smooth, slick) Arthritic joints looks yellow or grayish, with thinning of the cartilage and even erosions. Spurring of bone develop around the edges of the toe bone and the metatarsal head. This spurring further restricts the motion of the joint and contributes to continuation of the joint cartilage erosion. The ability of the toe to bend or flex up or down is affected. Shoes and even walking barefoot are painful.

How does this develop?

It is uncertain about the true cause but it is evident that there are several things to suspect. Often patients have a first metatarsal that is longer than the average, even as long or longer than the second metatarsal. This is thought to cause the joint to press into the ground harder with every step because ideally there should be an arch or parabola or curve across the ball of the foot. Secondly, mobility of the first ray (toe, metatarsal, and the next bone called the cuneiform). Too much mobility at the end of each step interferes with the normal gait sequence. The metatarsal is pushed a little too high, the muscles which pull the great toe down for stability at the end of the stride are unable to effectively work. The result is jamming of the toe against the metatarsal head and gradual development of spurring and widening of the joint. Thirdly, there can be a trauma such as kicking or dropping something on the foot. It may damage the cartilage which would not show up on an xray but will result in arthritis many years later.

What does it feel like?

Painful, dull aching. Sometimes, the pain can go up the foot, ankle and leg. The mechanics of the great toe joint are important. When it is unable to move properly, the demand continues but goes upward. Shorter steps, even slight intoeing can occur unconsciously to avoid moving the painful arthritic joint.

Treatment: whats available?

Nonsurgical
Treatment begins with anti-inflammatory medications to control, pain, swelling, heat and redness. Some improvement is seen in about 10 days. Shoes that have a stiff bottom or sole and a long last or top so there is less pressure against the toe or forefoot. A rocker sole can be applied to some shoes to reduce the bending of the severely arthritic joint. This is usually done for people with poor general health and elderly. Cortisone injections have been given but in our experience this gives very short lived relief. Alterations to shoes, or orthoses may take several weeks to have an effect. Physical therapy to gently relieve the tension of the small muscles around the joint have helped many people, at least for the short run.

Surgery

Surgery has come a long ways and varies greatly depending on the experience and training of the surgeon. Cheilectomy which is a trimming of the spurs around the joint give temporary relief. It is an old procedure that is not performed by itself very often any longer. Although it sounds like it would work, cheilecomy does not address the cause of the problem.

Osteotomies, or cut in the bone, are preferred today. They are performed on active people, and there are several kinds of osteotomies and generally work very well to open the joint space or allow the remaining good cartilage to be used. They are called joint preservation procedures.

Joint fusion or arthrodesis is preferred by some surgeons to relieve pain. To fuse the joint, a small amount of the joint is removed from both sides and the joint is fixated for permanent stiffness. It does remove the joint motion completely and eliminates the bone on bone arthritic pain. However it affects the normal biomechanics of the foot. Wearing a rocker soled shoe is usually necessary following the fusion because the demand for motion at the first MP joint shifts to the side of the forefoot, ankle and leg. The toes may become angled. Many patients are happy with the relief that they get ,however.

Artificial joint replacement

Some surgeons favor replacing the joint with an artificial joint similar to what is done in the knee or hip. One or both sides of the joint is removed and the space is filled with an implant. There are many kinds of implants but they all act as spacers to eliminate pain and hopefully give some motion. Generally implants are given to older patients who are also more sedentary.

Postoperative Healing

It will take about eight weeks before the bones and soft tissues are well healed. This is generally true for any procedure that is performed. During the healing time you will wear either a surgical shoe or walking boot to protect the area. Dressings stay on only 2 weeks but the special shoe or boot is worn longer. Most of the time you will not have any sutures to remove because absorbable sutures are often used. X-rays are taken periodically to assess your healing.