Managing Hallux Rigidus In The Athlete

By Mark A. Caselli, DPM

Hallux rigidus is a painful and insidious condition that can lead to significant limitations in an athlete’s ability to perform. The condition is characterized by a limitation of motion in the first metatarsophalangeal joint (MTPJ), chiefly in the direction of dorsiflexion. This limitation of motion is caused by a reactive proliferation of bone along the dorsal aspect of the joint and is associated with painful, degenerative arthrosis of the first MTPJ. There are an extensive number of conditions that can result in hallux rigidus (see “A Review Of Potential Hallux Rigidus Etiologies” below). Inflammatory conditions such as gouty, psoriatic or rheumatoid arthritis may lead to symptoms of pain and limitation of motion in the first MTPJ. Longstanding hallux valgus may also be associated with secondary degenerative joint changes. Hallux rigidus typically presents as an isolated arthritis in the young adult without a systemic arthritic condition. This suggests the degenerative process is caused by some local pathologic alteration in the first MTPJ. Secondary joint degeneration may occur after a recognized traumatic event. Other theories suggest hallux rigidus is caused by extra strain on the first MTPJ in a pronated foot or by an elevated first metatarsal, resulting in a limitation of hallux dorsiflexion. In any case, the condition tends to be progressive. Keep in mind that radiographic findings may be negative if the condition is early and mild. In more advanced cases, radiography may reveal joint space narrowing, osteophyte formation and loose bodies. Secondary degenerative changes in sesamoids are not uncommon. Pain about the first MTPJ is the presenting symptom of patients who have hallux rigidus. The patient may or may not be aware of the limitation of joint motion. Given the limitation of dorsiflexion, patients may complain of increased difficulty with activities that require greater dorsiflexion demands, such as walking up an incline, squatting or running. Any activity that requires significant dorsiflexion of the first MTPJ results in painful impingement or jamming. Intolerance of significant heel height is common because of the requisite dorsiflexion of the first MTPJ required to fit into the shoe. You may note swelling around the joint and palpate a dorsal bony proliferation. How Hallux Rigidus Affects Different Types Of Athletes Hallux rigidus can present several problems for runners. The size of the exostosis can result in shoe rubbing and irritation from the toe box of the shoe. Stiffness of the first MTPJ may result in abnormal biomechanics and the runner may compensate by running on the lateral border of the foot or abducting the foot to roll over the medial aspect of the hallux. These forms of compensation often lead to both foot and proximal leg pain. In ballet dancers, approximately 90 to 100 degrees of dorsiflexion at the first MTPJ is necessary to achieve full releve onto demi pointe. Limited motion of the hallux, resulting from hallux rigidus, often leads to faulty mechanics when attempting to achieve full demi pointe. To accomplish this, the dancer will roll laterally onto the lesser metatarsals, thereby sickling in. This faulty maneuver can cause lateral ankle sprains and malalignment problems. It is common to see impingement spurs in the first MTPJ in older dancers. They are often caused by direct impingement of bony surfaces in dorsiflexion or from capsular avulsions associated with sprains, resulting in further progression of the hallux rigidus. Hallux rigidus occurs frequently in tennis players due to the excessive dorsiflexion of the first toe during play. Athletes further exacerbate injury to the first MTPJ and the resultant hallux rigidus when they make a quick stop after charging toward the net. The impaction of the toe onto the anterior aspect of the shoe can lead to jamming and damage to the MTPJ. The court surface and shoe design play a significant role in the traction and the impaction of the toes. Hard court and wood surfaces are associated with greater traction than clay or grass courts. Consequently, toe impaction is more common with hard court or wood surfaces. In baseball, the pitcher subjects the hallux of the pivot foot to repetitive microtrauma. During delivery, the great toe lies over the edge of the rubber. The pivot foot rotates nearly 90 degrees at push-off, causing compression and torque at the first MTPJ.

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