Hallux Rigidus
Jessica J.M. Telleria, MD
John Y. Kwon, MD
Dr. Kwon or an immediate family member has received royalties from Paragon 28 and Trimed; serves as a paid consultant to or is an employee of Medline, Medshape, and Paragon 28; and has stock or stock options held in Medshape. Neither Dr. Telleria nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.
ABSTRACT
Hallux rigidus is a progressively painful, degenerative condition of the hallux metatarsophalangeal (MTP) joint. It is characterized by loss of motion, periarticular osteophyte formation, cartilage wear, and ultimately eburnation of the joint surface. Initial conservative management includes activity and shoe wear modification, carbon fiber inserts, NSAIDs, and steroid injections. A variety of joint-sparing procedures have been described for earlier stages of disease. These include cheilectomy, distal metatarsal or proximal phalanx dorsiflexion osteotomies, and interpositional arthroplasty. In advanced disease, first MTP arthrodesis has long been a reliable treatment option with high patient satisfaction. Historically, total joint arthroplasty has demonstrated poor survivorship and unacceptable outcomes. However, recently hemiarthroplasty with metallic or polyvinyl alcohol hydrogel implants have demonstrated encouraging results.
Introduction
The term hallux rigidus is used to describe a painful degenerative condition of the hallux metatarsophalangeal (MTP) joint. Hallux rigidus is characterized by progressive loss of joint motion, joint space narrowing, and osteophyte formation, which lead to pain and declining physical function. The condition was first reported in 1887 as a plantarflexed hallux at the first MTP joint with degenerative arthritis.1,2
Etiology and Pathophysiology
Hallux rigidus is believed to be incited by a trauma event to the hallux, as in an intra-articular fracture or a turf toe injury, or by repetitive, cumulative microinjury.3,4 Any loading injury to the hallux can cause compressive or shear forces across the joint and, in association with hyperdorsiflexion or plantar flexion, can cause acute chondral or osteochondral injury. Not all patients recall such an injury, however. In other cases, an acute injury to the hallux may uncover long-standing but previously asymptomatic degenerative changes.
After articular cartilage is damaged, loss of articular cartilage and alteration in bony anatomy progress as in other posttraumatic arthritic conditions. An initial softening of articular cartilage is related to depletion of the matrix proteoglycans. Early fibrillation results from a roughening of the articular surface incurred by unmasking and fragmentation of the collagen fibril structure. As the disease progresses, clefts and fissures form, eventually resulting in full-thickness cartilage loss, eburnation of the bony surfaces, formation of subchondral cysts, and osteophyte formation.5
In addition to trauma, several factors are believed to be related to the etiology of hallux rigidus or a predisposition to the condition. These include female sex, family history, hallux valgus interphalangeus, metatarsus adductus, and metatarsal head morphology.4,5,6,7,8,9,10 Hallux rigidus has long been associated with metatarsus primus elevatus, although this condition was found to be a compensatory deformity often corrected by surgical treatment of hallux rigidus.4,5,11 Another study found no relationship between the two conditions.12 No association has been found between hallux rigidus and hindfoot contracture, abnormal foot posture, first ray hypermobility, metatarsal length, or the patient’s occupation or shoe wear.4,11
The differential diagnosis includes crystalline disorders such as gout and pseudogout, rheumatoid arthritis, other types of inflammatory arthritis, and septic arthritis. Sesamoiditis, sesamoid fracture, turf toe injury, acute isolated osteochondral injury to the hallux MTP joint, hallux varus, and hallux valgus can cause pain around the joint but typically do not lead to joint space narrowing or other radiographic signs of arthritis of the hallux MTP joint.
Clinical Evaluation
Physical Examination
Patients report pain and physical limitation. Early in the course of hallux rigidus, pain often occurs only during
activities requiring an increase in motion or loading of the hallux MTP joint, such as running or wearing high-heeled shoes. The symptoms tend to be intermittent and easily tempered with NSAID use, shoe wear modification, or slight changes in activity. As synovial thickening and inflammation increase with further degeneration of articular cartilage, the symptoms become more consistent. The patient begins to have progressive loss of joint motion, and activities of daily living become more difficult. As joint space narrowing and dorsal osteophyte formation progress, painful impingement causes increasing difficulty with shoe wear. Simple activities such as prolonged walking or standing can elicit symptoms.
activities requiring an increase in motion or loading of the hallux MTP joint, such as running or wearing high-heeled shoes. The symptoms tend to be intermittent and easily tempered with NSAID use, shoe wear modification, or slight changes in activity. As synovial thickening and inflammation increase with further degeneration of articular cartilage, the symptoms become more consistent. The patient begins to have progressive loss of joint motion, and activities of daily living become more difficult. As joint space narrowing and dorsal osteophyte formation progress, painful impingement causes increasing difficulty with shoe wear. Simple activities such as prolonged walking or standing can elicit symptoms.
An inflamed and tender hallux MTP joint is found on physical examination. Erythema may be present, although typically not the cherry-red hyperemic inflammation characteristic of an acute gout flare-up. Although the dorsal soft-tissue envelope is usually intact, the patient (especially a patient with diabetic neuropathy) may present with skin ulceration. The patient may have a history of wearing ill-fitting shoes. With MTP joint palpation, the patient may experience tenderness secondary to chronic bursitis, synovitis, tenosynovitis of overlying extensor tendons, or painful dorsal spurs. Range-of-motion restriction depends on the stage of the disease; terminal dorsiflexion (impingement test) and plantar flexion elicit pain. The range of motion should be compared with that of the lesser toes and contralateral hallux MTP joints. Typically, the hallux and lesser toe MTP joints should have similar gross dorsiflexion on physical examination. Pain during midrange motion or gentle loading of the MTP joint (grind test) indicates a more profound joint cartilage loss. Clicking, catching, or grinding is found in relatively advanced hallux rigidus. Neuritis or loss of sensation to light touch can result from compressive neuropathy of the terminal branch of the superficial peroneal nerve, typically as a result of shoe pressure over the dorsal spur. In the absence of a comorbid condition such as peripheral vascular disease, perfusion of the toe is usually maintained.
Radiographic Examination and Classification
The radiographic examination requires AP, oblique, and lateral weight-bearing views of the affected foot. Plain radiographs reveal joint asymmetry, joint space narrowing, sclerosis, subchondral cyst formation, osteophyte formation, and toe deviation at the MTP joint. The level of severity depends on the stage of the disease. Joint space narrowing and toe alignment are best seen in the AP view, and dorsal spur formation is best seen in the lateral view. The oblique may be helpful in assessing patients with primarily dorsal cartilage loss but retained plantar joint space. MRI or CT is rarely required for diagnosis but may be useful if the differential diagnosis is unclear. Similarly, laboratory studies or joint aspiration can be useful to rule out crystalline disorders but typically are not required unless the diagnosis of hallux rigidus is unclear.
The Coughlin grading system is commonly used to guide treatment in conjunction with clinical findings.5 In grade 0, the patient has mild pain only during recreational activity or while wearing high-heeled shoes. Examination reveals slight tenderness to palpation but no clinical deformity. Loss of range of motion is minimal. Dorsiflexion is approximately 40° to 60°, or 10% to 20% less than in the normal contralateral joint. Radiographic findings are essentially normal. In grade 1, the symptoms are similar, but examination reveals tenderness, a palpable tender dorsal spur, and dorsiflexion of 30° to 40° (20% to 50% less than in the normal contralateral joint). The grind test does not elicit pain. Radiographs reveal a small dorsal spur (mild to moderate osteophyte formation) but minimal joint narrowing, sclerosis, or change to the articular morphology. A patient with grade 2 hallux rigidus reports more consistent pain, pain with activities of daily living, and greater difficulty with shoe wear than in grade 1. Range of motion is more restricted and dorsiflexion is 10° to 30°, or 50% to 75% less than at the normal contralateral joint. The osteophytes are palpable and tender. Radiographs reveal mild to moderate (less than 50%) joint space narrowing, mild to moderate sclerosis, and osteophyte formation extending medially and laterally with increased dorsal prominence. Typical periarticular arthritic changes of the sesamoids are not profound, although irregularities may appear. In grade 3, the patient has near-constant pain during activities of daily living and increased difficulty with shoe wear. Range of motion is restricted to dorsiflexion of no more than 10°, or 75% to 100% less than at the normal contralateral joint side, with loss of as much as 10° of plantar flexion. Osteophytes are clinically palpable and tender. Patients report pain at the terminal range of motion but may not have increased pain with the grind test. Radiographic findings are similar to those in grade 2, but with more than 50% narrowing of the joint space, greater cystic changes and sclerosis, and greater sesamoid involvement (Figure 1). The radiographic and clinical findings in grade 4 are consistent with those of grade 3, but the grind test is positive.
Nonsurgical Treatment
The nonsurgical treatment of hallux rigidus is similar to that of other degenerative arthritides and must be tailored to the individual needs of the patient. The decision to manage hallux rigidus nonsurgically depends mainly on the patient’s symptoms, limitations, and activity level
because radiographic grade has been shown to correlate poorly with symptoms.13 In general, nonsurgical treatment consists of the use of NSAIDs, injections, immobilization, stiff carbon fiber inserts, shoe wear modification, and activity modification.
because radiographic grade has been shown to correlate poorly with symptoms.13 In general, nonsurgical treatment consists of the use of NSAIDs, injections, immobilization, stiff carbon fiber inserts, shoe wear modification, and activity modification.
 FIGURE 1 Weight-bearing lateral (A) and AP (B) foot radiographs showing grade 3 hallux rigidus. |
Hallux rigidus grade 0, 1, or 2 usually can be effectively managed with NSAIDs, toe strapping, and shoe stretching to accommodate early osteophyte formation. Shoes with a stiff sole or a rocker-bottom sole can reduce the transmission of forces across the MTP joint and limit its motion. The patient is instructed to limit inciting activities. Grade 3 or 4 is managed with the same modalities. A Morton extension can be used to further reduce MTP joint motion; care is required, however, because a shoe insert reduces the space in the toe box and thereby can increase dorsal spur pressure. The use of shoes with a deep toe box is recommended. A steel shank can be custom inserted into the midsole of the shoe to further increase rigidity.
Nonsurgical treatment has been found to be effective. At a mean 14.4-year follow-up of nonsurgical treatment in 22 patients (24 feet), patients agreed with the earlier decision not to have surgery for 18 of the feet (75%), despite an overall lack of symptom improvement and worsening radiographic findings.14 These study findings are somewhat surprising because patients generally report a stepwise decline in function and an increase in symptoms, as in other degenerative arthritic conditions.
Intra-articular cortisone can be used albeit sparingly. Administration into the MTP joint becomes more difficult as the joint space narrows and may require the use of fluoroscopy, ultrasound, or consultation with an interventional radiologist. The deleterious effects of cortisone (in particular, thinning of the dorsal soft tissues and impaired wound healing) must be taken into account if surgical intervention is later considered as the disease progresses. In one series, intra-articular steroid injection into the MTP joint and gentle joint manipulation led to clinical improvement of 6 months’ duration in patients with mild to moderate hallux rigidus.15 However, patients with severe hallux rigidus had little symptomatic relief and required surgical treatment.
Surgical Treatment
The decision to undertake surgical treatment is based not only on the disease grade but also on the patient’s symptoms and response to nonsurgical treatment. The patient’s personal goals and perception of the effect of the disease on quality of life are paramount. The appropriate nonsurgical modalities must be tried before surgical intervention is pursued. Few level I studies have compared the available surgical modalities, and a 2010 Cochrane review identified only one clinical study that met the inclusion criteria.16 More robust randomized controlled studies are needed to determine the efficacy of interventions for the
treatment of hallux rigidus. A review of evidence-based reports found that no definitive conclusions could be drawn from adequately powered studies using appropriately validated outcome measures.17 There is a need for high-quality level I studies. Nonetheless, many studies have shown the benefits of surgical intervention. The available procedures are characterized as joint sparing, joint modifying, or joint ablation.
treatment of hallux rigidus. A review of evidence-based reports found that no definitive conclusions could be drawn from adequately powered studies using appropriately validated outcome measures.17 There is a need for high-quality level I studies. Nonetheless, many studies have shown the benefits of surgical intervention. The available procedures are characterized as joint sparing, joint modifying, or joint ablation.
Joint-sparing Procedures
Joint-sparing procedures typically are used for low-grade (grades 1 and 2) hallux rigidus after unsuccessful nonsurgical treatment. MTP joint synovectomy can be done as an isolated procedure, but usually a joint-modifying procedure is added. In a retrospective review of surgically treated osteochondral defects of the first metatarsal head, 14 of 24 patients had subchondral drilling and 10 had osteochondral autograft transfer.18 Patients with smaller lesions had a good result with either modality, but those with larger defects or subchondral cysts were more likely to benefit from osteochondral autograft transfer.
Joint-modifying Procedures
The joint-modifying procedures include cheilectomy, osteotomy, and MTP joint arthroscopy. Often these procedures are used in combination.
Cheilectomy
The most common joint-modifying procedure is cheilectomy, which is excision of the dorsal osteophytes and the degenerative dorsal portion of the articular surface of the first metatarsal head (Figure 2). Typically the dorsal 25% to 30% of the first metatarsal head is resected to facilitate clearance of the proximal phalanx during MTP dorsiflexion, with the goal of achieving approximately 90° of dorsiflexion intraoperatively. Cheilectomy is an effective surgical option for relieving symptoms directly over the prominent dorsal spur as well as limitations in motion from a bony block and associated dorsal joint wear pattern. This procedure was first described in 1930.10 In a review of patients with hallux valgus and hallux rigidus who were treated from 1920 to 1950, 68 patients underwent excision of the dorsal spur alone. Although a large number of these patients required additional surgery and/or nonsurgical treatment, good functional results were achieved.6 Cheilectomy became popular after a 1959 report of 90% satisfactory results at short-term follow-up.8 At a mean 9.6-year follow-up of 80 patients (93 feet), the largest study of cheilectomy reported that 86 of the cheilectomies (92%) were considered successful.5 The mean improvement in dorsiflexion was from 14.5° before surgery to 38.4° after surgery. Of the nine patients who had midrange intra-articular pain (positive grind test) before surgery, five later underwent arthrodesis and the remaining four had a self-reported fair or poor outcome. The researchers found that the clinical outcome was not correlated with the radiographic appearance of the joint at final follow-up. A recent gait analysis study of 17 patients found increases in MTP joint range of motion and peak sagittal-plane ankle push-off power at 1-year follow-up after cheilectomy.19
In general, cheilectomy has been found effective, especially for patients with low-grade hallux rigidus. At a mean 56-month follow-up, none of 25 patients had required additional surgical intervention after cheilectomy, and only 3 patients reported minimal discomfort.9 Of 20 patients treated with isolated cheilectomy over a 6-year period, 18 (90%) reported near-complete pain relief; 16 (74%) had improvement in range of motion, and 13 (68%) had more than 30° of dorsiflexion with minimal progression of the degenerative process.20 In another clinical study, 42 patients treated with cheilectomy had subsequent improvement in range of motion, return to previous level of activity, dissipation of pain (within 3 months), and a high level of satisfaction.21
Simple cheilectomy appears to be less effective in patients with advancing disease and increasing joint involvement than in patients with lower-grade disease. A review of 58 cheilectomies in 53 patients found that 53% of patients had a satisfactory result, 19% had a satisfactory result with reservations, and 28% had an unsatisfactory result.22 When clinical results were correlated with the radiographic grade of the joint, the researchers found an unsatisfactory result in 15% of patients with
grade 1 disease, 31.8% of those with grade 2 disease, and 37.5% of those with grade 3 disease. A separate study of 52 patients who underwent a dorsal cheilectomy through a medial approach found a 90% satisfaction rate at a mean 63-month follow-up, improved patient-reported outcomes scores, and an increase in dorsiflexion range of motion from 19° to 39°.23 None of the 82% of feet with grade 1 or 2 disease required a subsequent procedure, but the majority of the 18% with grade 3 disease had continuing pain and 25% required arthrodesis during the study period.
grade 1 disease, 31.8% of those with grade 2 disease, and 37.5% of those with grade 3 disease. A separate study of 52 patients who underwent a dorsal cheilectomy through a medial approach found a 90% satisfaction rate at a mean 63-month follow-up, improved patient-reported outcomes scores, and an increase in dorsiflexion range of motion from 19° to 39°.23 None of the 82% of feet with grade 1 or 2 disease required a subsequent procedure, but the majority of the 18% with grade 3 disease had continuing pain and 25% required arthrodesis during the study period.
 FIGURE 2 Schematics showing a cheilectomy. A, Dark gray areas demonstrate the planned bony areas to be resected by cheilectomy. B, The hallux metatarsophalangeal joint is shown after cheilectomy. (Reproduced from Seibert NR, Kadakia AR: Surgical management of hallux rigidus: Cheilectomy and osteotomy (phalanx and metatarsal). Foot Ankle Clin 2009;14[1]:9-22. Copyright 2009, with permission from Elsevier.) |
However, good results have also been reported regardless of the radiographic grade of the joint, especially in older patients. Fifty-seven of 67 patients who underwent cheilectomy were available at a mean 65-month follow-up.24 Radiographic disease grade was not used in the study, but patients with symptoms of advanced disease were excluded. An overall satisfaction rate of 78% was found, with a 91% satisfaction rate in patients older than 60 years, including those requiring a salvage procedure.
An isolated cheilectomy is an excellent treatment option that typically is reserved for lower-grade hallux rigidus, although it appears to have some benefit in more advanced disease. Careful patient selection and preoperative counseling as to expectations is important.
Osteotomy
Osteotomies have been used to treat hallux rigidus when joint preservation is preferred. These joint-modifying procedures include osteotomies of the proximal phalanx and distal first metatarsal. Proximal osteotomies of the first metatarsal have been described primarily for the treatment of metatarsus primus elevatus.
The Moberg osteotomy, a dorsiflexion osteotomy of the proximal phalanx, can be beneficial for patients with hallux rigidus (Figure 3). As hallux rigidus advances, dorsiflexion is limited to a greater extent than plantar flexion. The use of a dorsal closing wedge osteotomy of the proximal phalanx repositions the toe into an extended position, thus altering and improving the arc of motion. This procedure typically is done in conjunction with cheilectomy and was first used in pediatric patients with painful hallux rigidus.6 Ten adolescent patients had improvement in mean dorsiflexion from 5° before surgery to 44° at a mean 28-month follow-up.25 Seventeen patients (24 feet) with grade 1 or 2 disease underwent Moberg osteotomy and cheilectomy.26 At a mean 5.2-year follow-up, overall satisfaction was high: 96% of the patients said they would undergo the procedure again, 58% reported no pain, and 42% reported only mild pain. Another study found that all 34 patients who underwent dorsal cheilectomy with a combined Moberg and Akin biplanar osteotomy had radiographic healing at an average 22.5-month follow-up; 90% reported a good or excellent result, with pain relief, improvement in function, and decreased shoe wear limitation.27 Only one patient required additional surgical intervention for hardware removal. The role of cheilectomy and proximal phalangeal extension osteotomy in treating advanced disease was examined in 81 patients.28 At a mean 4.3-year follow-up, the mean dorsiflexion of the first MTP joint had improved 27° (from 32.7° before surgery to 59.7°). The average AOFAS (American Orthopaedic Foot and Ankle Society) score had improved from 67.2 points to 88.7 points. Radiographs of the interphalangeal joint showed no evidence of interphalangeal joint arthritis. Sixty-nine patients (85%) were satisfied with the results of treatment; four patients (5%) subsequently underwent arthrodesis to treat persistent symptoms at the first MTP joint. A recent study of 40 patients with grade 2 or 3 disease, and a mean of 2.7-year follow-up after dorsal phalangeal extension osteotomy, demonstrated improvement in AOFAS scores from 51.7 preoperatively to 88.8 postoperatively, as well as improvement in first MTP dorsiflexion from 20.3° to 55.7° after surgery.29 Removal of symptomatic screws was performed in two patients.
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