The presenting symptoms of hallux limitus are variable and commonly include pain, stiffness, or limited motion of the hallux. The symptoms appear gradually with a deep and achy pain as the most frequent presentation. The degree of discomfort usually correlates with the level of activity such as bending, walking, and standing and tends to progressively increase throughout the day.
Often, the pain and stiffness are exacerbated in cold temperatures. Symptoms vary depending on stage and are aggravated by activity and footwear. Most often the formation of a dorsal bone spur around the big toe joint will lead to direct pressure against the shoe and exacerbate the pain or result in callus formation. In addition, symptoms of paresthesia or neuralgia to the big toe may develop secondary to chronic pressure from the bone spur. Pain is exacerbated by shoe gear that lacks support or drives the big toe joint into dorsiflexion beyond its limited range of motion (ie, high heels or flip flops). Pain, swelling, and crepitus can be encountered in the MTP joint with activity and walking. With time, the mobility of the big toe joint diminishes and dorsiflexion becomes limited.
Most patients exhibit pain to other parts of the body secondary to an altered gait pattern.
Plain radiographs are used to determine the type and severity of arthritis, but the pain may not coincide with the radiographic findings. Weight-bearing anteroposterior (Figure E5–2A) and lateral views are the most useful images (Figure E5–2B). The degree of involvement can be classified into four stages. Stage I is mild disease with minimal adaptive changes, but patients may feel pain at the end of range of motion. Stage II is defined as moderate hallux limitus and has bone spur formation displaying signs of joint adaptation. Stage III, severe hallux limitus, is associated with joint deterioration and pain on full range of motion. Stage III displays significant loss of cartilage on radiographic imaging. Stage IV, better known as ankylosis, indicates obliteration of the joint space. Patients with stage IV disease have severely limited or no motion at the big toe joint.
Radiographs showing hallux limitus. (Used, with permission, from M. Dini, DPM.)