Hallux Rigidus: Conservative Treatment

CHAPTER PREVIEW

CHAPTER SYNOPSIS:

Limited great toe motion, primarily loss of dorsiflextion, and painful motion are the hallmark. Radiographs may show loose bodies dorsally, a condition that generally does not respond to conservative treatment.

IMPORTANT POINTS:

1

Nonoperative treatment is aimed at reducing pain; there is no evidence that range of motion will improve. Oral medication, restricting activity, and providing shoe modification with or without insole support are first-line treatments.
2

Corticosteroid injection is helpful but not curative.

CLINICAL PEARLS

1

The goal of shoe modification and insoles is to limit passive dorsiflexion of the metatarsophalangeal joint of the great toe.
2

Heel height should be low.
3

There may be a role for injection with haluronan.

CLINICAL/SURGICAL PITFALLS:

1

Loose body presence leads to local irritation dorsally and may not respond to shoe modification and insoles.
2

Multiple intra-articular injections with corticosteroid may lead to worsening of the clinical condition (i.e., pain).

VIDEO AVAILABLE:

NA

HISTORY/INTRODUCTION/SCOPE OF THE PROBLEM

Hallux rigidus is defined as a painful restriction in dorsiflexion of the hallux at the first metatarsophalangeal joint. It has been documented that approximately sixty degrees of dorsiflexion is required for normal gait. The primary role of the hallux is to dorsiflex on the metatarsal during the propulsive phase of gait so that the body’s center of mass can pass forward from the loaded foot to the opposite foot. The symptomatic development of hallux rigidus is related to the inability of the joint to perform this action with stiffness and pain. Conservative management is the initial treatment for hallux rigidus. The outcomes of nonoperative treatment depend on the patient’s symptoms and amount of degeneration of the joint.

NONOPERATIVE TREATMENT

Nonoperative treatment is aimed at reduction of the local inflammatory process and decreasing the dorsiflexion forces that lead to painful impingement. Initial treatment consists of nonsteroidal anti-inflammatory medications, which can alleviate the synovitis of the joint. Activity modification such as avoiding high-impact loading of the foot such as running or jumping may help but is not always an appealing option for the more active population.

Orthotics have been shown to provide greater and longer-term pain relief than anti-inflammatory drugs alone. Grady’s analysis of 772 patients at a Veterans Affairs Medical Center successfully treated over half of their patients with conservative care consisting of Morton’s orthotics, shoe sole modification, or corticosteroid injections. Of these patients successfully treated, 84% were treated with orthotics, 10% with a change in soles, and the remaining 6% with corticosteroid injections.

Conservative care of early stage hallux rigidus may include the use of a dancer’s pad ( Fig. 34-1 ) or orthotic custom made with a cut-out pad. These two types of pads are used in an attempt to increase the plantarflexion of the first metatarsal to improve range of motion of the metatarsophalangeal joint. As we progress into more advanced stages of hallux rigidus, the dancer’s pads will no longer be effective. At this stage, treatment changes to a more rigid extension to decrease painful range of motion. Another short-term solution for later stages is to use a turf toe strap ( Fig. 34-2 ) to limit range of motion.