What are Hallux Limitus (HL) and Hallux Rigidus (HR)?
Simply put…Hallux Limitus/Rigidus is an arthritic condition that affects the motion and function of the big toe (hallux) joint. Hallux Limitus (HL) is a limitation of the motion/function of the big toe joint. Hallux Rigidus (HR) is a more progressive limitation of motion/function to the level of rigidity (no motion).
For the sake of discussing the pathomechanics of these two closely related conditions, we will refer to HL only. As stated above, HL is a progressive arthritic process which occurs within the articular surfaces (cartilage) of the two bones that comprise the big toe joint. These two bones are called the 1st metatarsal bone and the proximal phalanx of the hallux (big toe).
For a diagram of the bones of the foot, please see http://www.podcare.com/images/Foot-Anatomy.jpg .
HL can develop from one of two causes…congenital (from birth) and acquired (develops from some type of injury). Numerous types of congenital malformations of the bones of the first metatarsal-phalangeal joint-1st MPJ-(big toe joint) can lead to HL. Extensive lengthening and/or shortening of these bones, as well as malposition of the bones can lead to HL later in life. Acquired HL results from an injury to the one, or both, of the cartilage surfaces of the proximal phalanx and/or 1st metatarsal. Damage to the articular surface(s) lead to degenerative arthritis over time and the development of HL/HR.
Signs and Symptoms Associated with HL/HR
As mentioned above, HR is just a more progressive condition of HL. The distinction between the two entities is somewhat of an arbitrary nature, and is more an exercise in semantics. The initial sign of HL is a limitation of motion within the 1st MPJ. This limitation of motion causes increased pressure within the joint and subsequently pain from inflammation-referred to as capsulitis.
Progressive limitation of motion leads to the beginning stages of degenerative arthritis. When arthritis begins to develop within the joint, typically a bump, or knot, will develop on top of the joint. As the degeneration of the cartilage progresses, the arthritis progresses also….leading to increased pain. Once the arthritis is sufficient to prevent any motion of the joint, the condition is referred to as HR. Progressive HR can lead to a significant bump, or knot, on top of the foot many times referred to as a dorsal bunion. An excellent referral site for more information about dorsal bunions, HL, and HR can be found here.
Pain associated with both conditions is classic arthritic-type pain within the joint….a deep aching-type pain occurring during, and many times, after activity. Patients with mild conditions may only experience pain with excessive activity and exacerbated by non-supportive shoes. Moderate to severe conditions lead to pain with normal activity and any type of shoe gear.
More important than the pain at the site of the progressive arthritis, limitation of motion within the big toe joint causes significant changes to the patient’s normal gait pattern. During normal ambulation, the majority of body weight is propagated through (and out the end of) the 1st MPJ.
When there is limitation of the ability of the hallux to dorsi-flex (move upwards), weight-bearing forces are transferred more to the outside of the foot. This causes significant gait alterations which may lead to compensatory pain (and progressive arthritis) in other parts of the same foot, opposite foot, knees, hips, lower back, and even into the neck and shoulders. It is for these reasons that severe cases of HL and/or HR need to be treated definitively.
Treatment for HL and HR
For ease of discussion, treatment of both conditions will discussed on a continuum of severity from mild, moderate, to severe. Mild conditions are many times treated successfully with various OTC (over-the-counter) measures. Shoe modification is the most common treatment.
Simply wearing more supportive shoes will reduce the pressure on the big toe joint and improve discomfort and function. Other treatments include shoe inserts or arch supports, OTC oral anti-inflammatory medications, ice-massage after activity, and cessation of exacerbating activities. If pain continues to exist and begins to cause any othersymptoms, professional care is recommended.
Moderate cases are treated with the above noted measures and the addition of physician-related modalities. The most common medical treatment is the use of intra-articular (within the joint) corticosteroid injections into the 1st MPJ. Varying types and strengths of corticosteroids (usually combined with some type of local anesthetic) are used to reduce inflammation in the tissues within, and around, the symptomatic joint(s).
Secondly, prescription, custom, functional-orthotics are very useful in treating (and limiting the progression) of arthritis. A special addition-Morten’s extension-is fabricated into the orthosis to help alleviate excessive pressure within the 1st MPJ and improve pain and function. Various forms of immobilization can help reduce significant acute inflammation, but provide little to no long-term benefits. Severe cases of HL/HR should be treated by a properly trained and certified podiatric physician.
Severe cases of HL/HR lead to progressive pain/arthritis and can lead to significant gait alterations and compensatory pain in the feet, knees, hips, and back. It goes without saying that ALL of the treatments mentioned above should be attempted (or at least recommended) in all patients with severe conditions. If continued pain and lifestyle alterations persist, surgical intervention is a viable option.
There are a number of surgical procedures that can be performed for HL/HR. Specific description(s) of these various procedures are beyond the technical scope of this presentation. If one is interested in learning more about the technical aspects of the procedures, a good reference site can be found here. I perform all, or a combination of all, the procedures that are referenced at the above noted URL.
The specific type of procedure that is performed is dependent on a number of factors. These include age, activity level of the patient, severity of the condition, individual foot type and biomechanics, future activity requirements, and patient expectations. It should be pointed-out that severe cases of HL/HR include varying levels of osteo-arthritis within the 1st MPJ or big toe joint. There is no specific ‘cure’ for progressive arthritis and procedure selection is influenced greatly by the underlying pathomechanics involved and individual patient expectations.
Generally speaking there are two categories of procedures: joint-preservation procedures and joint-destructive procedures. The joint preservation procedures involves resecting various portions of osteo-arthritic bone whereas joint-destructive procedure involves replacingvarious portions (or all) of the joint. I perform all these procedures on an out-patient basis under a combination twilight/local anesthetic, and take less that one hour. Patients typically go home the same day and are placed in a cam-walker with partial weight with the aid of crutches the first weekend. Progression into a surgical shoe takes place within 2-3 weeks and back into tennis shoes within 4-6 weeks.
Physical therapy is normally recommended to reduce pain and swelling, increase range of motion, and enhance progression into normal shoes/activities. I recommend prescription, functional-orthotics for all patients who have any type of surgical procedure for HL/HR to improve foot function and limit potential reoccurrence.
Overall results depend upon individual patients/conditions; however, the majority of patients find the procedure extremely gratifying with a return to normal shoes and activities.