Hallux Rigidus: Conservative care

Dr.Rajiv ShahFoot & ankle surgeon

‘Foot & ankle orthopaedics’Vadodara, Surat

• Reported in 1887 by Davies-Colley - Hallux Flexus

• Cotterill coined the term Hallux Rigidus

• DuVries in 1959 and Moberg - hallux rigidus is the most common condition to affect the first MTP joint

• Also called as- hallux limitus- dorsal bunion- hallux dolorosus - hallux malleus- metatarsus primus elevatus (MPE)

History

• Painful condition of great toe MTP joint

• Characterized by - Restricted motion (mainly

dorsiflexion)

- Proliferative periarticular

bone formation

Hallux Rigidus

Etiology

Trauma

Intra articular fracture

Single episode Repetitive micro traumas

Crush Injury Acute chondral/

osteochondral injury

Forced hyperextension/plantar flexion injury

Other Etiology

Congenital flattened/squared metatrsal head

Short first metatarsal

Long first metatrsal

Pes planus

Tight intrinsic muscles

Congruent MTP joint

Hindfoot pronation

Metatarsus primus elevatus

Dorsal and dorsolateral

exostosis

Bony ledgeIncreased bulk

around the joint

Constricting footwear Dorsal

exostosis enlargement

Limitation of dorsiflexion

Pain Swelling MTP synovitis

Late Stage

Initial Stage

Symptoms

• Swollen metatarsophalangeal (MTP) joint

• Everted gait

• Numbness develops over medial sensory nerve to the hallux

• Callus develops on lateral heel because of everted gait

• Hyperextension of hallux interphalangeal joint

Signs

• Initial stages - Nonuniform joint space narrowing- Widening and flattening of first

metatarsal head

• Advanced stages - Subchondral cysts and sclerosis of

metatarsal head- Widening of base of proximal

phalanx- Hypertrophy of sesamoids

Radiographic evaluation

Grade 0 Grade I

• Clinical- Only stiffness- Loss of passive motion

• ROM- Dorsiflexion 40-60

• Radiograph- Normal

• Clinical- Occasional pain- Pain at extremes of dorsiflexion

• ROM- Dorsiflexion 30-40 degrees

• Radiograph- Dorsal spur- Min joint narrowing- Min periarticular sclerosis- Minimal flattening of metatarsal head

Grade II Grade III

• Clinical- Nearly constant subjective painsubstantial stiffness pain through out ROM (but not at mid ROM)

• ROM - 10 degrees or less Dorsiflexion

• Radiograph- Grade 2+ substantial narrowing, periarticular changes,>25% joint space involved no dorsal side,sesamoids enlarged

• Clinical- Moderate to severe pain and stiffness- Pain just before maximal dorsiflexion

• ROM- Dorsiflexion 10-30 degrees

• Radiograph- Osteophytes- <25%dorsal joint space involved- Mild to moderate joint narrowing and sclerosis

Grade IV

• Clinical- nearly constant subjective pain andsubstantial stiffness - pain through out ROM+definite oain at mid ROM

• Radiograph- Grade 2+ substantial- narrowing,periarticular changes,>25% joint

space involved no dorsal side,sesamoids enlarged

• ROM 10 - degrees or less Dorsiflexion

Management

Conservative

Surgical

•Cheilectomy•Phalangeal osteotomy•Plantar flexion osteotomy•Arthroplasty•Arthrodesis

Management

Conservative Management

NSAIDs: reduces inflammation & pain due to synovitis

Modification of activities

Neurotropics: if neuritic pain Steroid injections

Conservative methods may be successful even in cases with severe hallux rigidus!

•Morton’s extension•Carbon fibre plate insert•Commercially available inserts•Custom mould inserts

Conservative Management

Tapping

Footwear modifications

Orthotics:To stiffen the fore foot

To offload forefootTo reduce the forefoot/MTP

joint motion

•Stiff insoles•Rocker bottom shoe•Still medial shank•Wide/deep toe box•Low heels

Joint manipulation

Success rate is up to 60%-70%!

That’s all…Thank you all…