Hallux Rigidus

Abstract

Hallux rigidus is arthritis of the big toe metatarsophalangeal joint. It is the commonest arthritic condition of the foot, second only to hallux valgus (bunion) associated with the big toe. Females are more commonly affected than males in all age groups, and the condition typically develops in adults in their fourth to sixth decades.

Keywords

Arthritis, big toe, hallux rigidus, pain, stiffness

Synonyms
Osteoarthritis or degenerative joint disease of the first metatarsophalangeal joint Osteoarthritis of the great toe
ICD-9 Code
735.2	Hallux rigidus
ICD-10 Codes
M20.20	Hallux rigidus, unspecified foot
M20.21	Hallux rigidus, right foot
M20.22	Hallux rigidus, left foot

Definition

Degenerative joint disease or loss of articular cartilage from the first metatarsophalangeal (MTP) joint leading to painful restriction of motion is called hallux rigidus. The normal range of motion of the first MTP joint is 30 to 45 degrees of plantar flexion to almost 90 degrees of dorsiflexion. The limited range of motion and pain with hallux rigidus are exacerbated by overgrowth of bone (osteophytes or “bone spurs”) on the dorsal aspects of the base of the proximal phalanx and the head of the metatarsal, which impinge on one another as the great toe dorsiflexes. Hallux rigidus is the second most common problem in the first MTP joint, after hallux valgus; 1 in 40 people older than 50 years will develop hallux rigidus.

In general, the cause is unknown, although it is associated with generalized osteoarthritis of other joints and repeated microtrauma (e.g., in soccer players). Sustaining repetitive turf toe-type injuries (hyper-dorsiflexion of the hallux MTP joint with stretching and attenuation of the plantar capsule and ligaments, ranging from a sprain to a complete rupture) may lead to this form of early joint degeneration. As the plantar capsuloligamentous complex of the first MTP joint is injured by hyperextension of the great toe, it may acutely compress the articular surfaces of the joint, causing articular damage, or become chronically unstable, predisposing the MTP joint to degeneration and hallux rigidus.

Symptoms

Patients typically report pain, either intermittent or constant, that occurs with walking and is relieved by rest. It is insidious in onset and may be associated with stiffness, swelling, and sometimes inflammation. On occasion, there can be locking due to a cartilaginous loose body. Patients may notice that they are walking on the outside of the foot to avoid pushing off with the great toe during the terminal stance and toe-off phases of the gait cycle. As degeneration increases, the pain may intensify and result in an alteration of gait.

Physical Examination

On inspection, there will usually be swelling around the first MTP joint with tenderness of the joint line. Dorsal osteophytes may be palpable and may cause irritation of overlying skin with shoe wear abrasion. Pain is reproduced with forcible dorsiflexion of the great toe, which is also restricted in range of movement. Plantar flexion may also be affected. Patients may have an antalgic (painful) gait, and single-stance heel raise may be difficult secondary to a painful MTP joint, as opposed to posterior tibial tendon deficiency. Findings of the neurologic examination, including strength, sensation, and reflexes, are typically normal.

Functional Limitations

Functional limitations include walking long distances, running any distance, and ascending stairs. As the severity increases, walking even short distances, daily errands, and standing for long periods may be difficult. Flexible shoes as well as shoes with a tight toe box may prove to be uncomfortable. This may lead to pressure areas dorsally over the osteophytes.

Diagnostic Studies

Plain anteroposterior and lateral standing radiographs will usually suffice in confirming the diagnosis ( Fig. 87.1 ). The signs are consistent with degenerative joint disease, namely, loss of joint space and congruency, large dorsal osteophytes (bone spurs), sclerosis (increased density of bone), and subchondral cysts. There may be evidence of a loose body. This disease process has been divided into three grades on the basis of the severity of radiographic and clinical findings, which help guide surgical treatment.

Grade I demonstrates small dorsal osteophytes with preservation of the MTP joint space on radiographic examination and typically intermittent pain with ambulation. Grade II demonstrates moderate dorsal osteophyte formation and asymmetric joint space narrowing radiographically and often constant pain with ambulation. Grade III has extensive osteophytes and severe dorsal and plantar joint space narrowing, often with noticeable loose bodies; clinically, patients will have constant pain with ambulation and significant limitation of motion.

Differential Diagnosis

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