e5-03: Hallux Limitus

Hallux limitus is a painful, acquired, progressive arthritic condition of the first MTP joint. Hallux limitus occurs in three groups: congenital, adolescents, and adults. Hallux limitus can present unilaterally or bilaterally, but the condition in both feet may not occur at the same stage of arthritis.

Multiple direct and indirect causes of adult hallux limitus have been proposed. Direct mechanisms include trauma, fractures, or turf toe sprains. Indirect forces include biomechanical deformities of the medial column of the foot. Aside from osteoarthritis, various associated factors have been implicated as the etiology of hallux limitus, including inflammatory diseases such as rheumatoid arthritis and gout.

Hallux limitus is a condition that can worsen with time and lead to the condition hallux rigidus. Hallux rigidus, the condition in which there is little or no motion of the big toe joint, is considered to be the end-stage form of hallux limitus.

A. Symptoms and Signs

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.

B. Imaging

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.

A. Conservative

Treatment for mild or moderate cases may include over-the-counter measures, but these measures may not stop the condition from progressing. Nonsteroidal anti-inflammatory medications may help reduce the swelling and ease the pain. The application of ice packs or contrast baths helps reduce inflammatory symptoms. Wearing a shoe with a wide toe box reduces the amount of pressure on the toe. A stiff-sole or rocker-bottom soled shoe helps decrease the pressure put on the big toe when walking. Custom orthotics with reverse Morton extension or Morton extension help eliminate the amount of bend in the big toe. Injection of corticosteroids may reduce swelling and pain. Ultrasound therapy or physical therapy may reduce inflammatory symptoms and provide better motion at the big toe joint.

B. Surgical

Surgery is recommended in patients whose condition has progressed or who have gotten no pain relief from conservative treatment. The type of surgery is based on the stage of hallux limitus. Stage I is typically treated with conservative measures. Cheilectomy is typically recommended when damage is mild or moderate such as in stage II. It entails the removal of bones spurs and reshaping of the first metatarsal head to allow the toe more room to bend. Stage III hallux limitus may be treated with an osteotomy to reposition the remaining cartilage of the first metatarsal head and/or a hemi-implant. Stage IV may be treated with arthrodesis (fusion) or arthroplasty. Arthrodesis involves fusing the bones together when the damage to the cartilage is severe. Once the damaged cartilage is removed, the bone is permanently fused with hardware. The patient will not be able to bend the toe at all. Arthroplasty entails the removal of bone from the joint (resection) with or without an implant. Joint resection is the procedure of choice in older or lower functional demand patients.

• If the patient has not responded to conservative treatment.

• There is severe pain from the MTP joint or bunion.