Managing Hallux Rigidus In The Athlete
This repeated action creates dorsal compression and stretching of the plantar plate and collateral ligaments. These athletes will likely present with joint pain, dorsal tenderness and edema. Synovial thickening and dorsal osteophytes may be palpable in more advanced cases. Initially, the limitation of dorsiflexion may be mild. However, the condition can progress to hallux rigidus with more marked restriction of motion. It is not uncommon to observe a hyperextension deformity of the hallux interphalangeal joint as a result of hallux rigidus. This hyperextension deformity develops as a result of compensation for lack of motion in the first MTPJ. The interphalangeal joint may experience increased stress as dorsiflexion of the MTPJ becomes more limited. One will also note palpable thickening and enlargement of the joint, which are due to osteophyte formation. You may also see an associated plantar callosity beneath the interphalangeal joint. A Guide To Initial Treatment The treatment of hallux rigidus is aimed at the reducing the local inflammatory process at the first MTPJ and decreasing the dorsiflexion forces that lead to painful dorsal impingement. The initial thrust should be to decrease the acute inflammatory reaction by emphasizing rest, NSAIDs and ice. One can use intraarticular steroid injections when oral medications are not effective. You can also recommend alternative conditioning (such as bicycling, swimming or running in water) that does not stress the great toe. Encourage athletes to perform passive range of motion exercises with an emphasis on dorsiflexion. The athlete should perform these exercises two or three times a day by grasping the base of the proximal phalanx of the great toe and maximally dorsiflexing the joint to tolerance at least 20 to 30 times. As the symptoms subside and the athlete returns to activity, you can protect the hallux from excessive dorsiflexion with taping. Apply the taping in a figure-eight loop around the proximal phalanx and attach it to the plantar surface of the foot. A Review Of Potential Hallux Rigidus Etiologies Traumatic • Osteochondral first metatarsophalangeal joint injury • Intraarticular first metatarsophalangeal joint fracture • Hallucal sesamoid dysfunction secondary to sesamoid fracture • Epiphyseal injury Anatomic/Structural • Abnormally long proximal phalanx of hallux • Abnormally long first metatarsal • Elevated first metatarsal Biomechanical • Hypermobile first ray • Excessive rearfoot pronation Metabolic • Arthritic conditions affecting the first metatarsophalangeal joint • Osteochondral defects of the first metatarsophalangeal joint Neuromuscular • Extrinsic and/or intrinsic muscle imbalance affecting the first ray Iatrogenic • Excessive elevation of the first metatarsal • Excessive lengthening of the first metatarsal • Excessive fibrosis • Malalignment of the first metatarsophalangeal joint • Septic arthritis Pertinent Pearls On Shoes And Orthoses Shoe gear plays an important role in managing hallux rigidus. Initially, you want to relieve the pressure placed on the enlarged joint by poorly fitting athletic shoes. This may be accomplished by emphasizing shoes with soft uppers or shoes with adequate depth and width of the toe box to accommodate the enlarged joint. Using a stiff-soled shoe can help decrease the dorsiflexion force. Shoe modifications can include an extended steel shank or a rocker bottom sole. Currently available athletic shoes termed “All Terrain,” “Off Trail Jogger,” “Trail,” and “Hiking” often have the characteristics of both a stiff and rocker sole, and can be used for many sports or conditioning activities. However, one should be cautious about using an excessively stiff-soled shoe since it may promote conditions such as Achilles tendinitis and shin splints. Shoes with these stiff soles may also interfere with motion. For example, they may impair the delivery of the high performance pitcher. A foot orthosis can also be a valuable tool in managing hallux rigidus. It should be fabricated to hold the longitudinal arch in a corrected position while incorporating a sufficient (at least 5 degree) “extrinsic” forefoot varus posting to raise the head of the first metatarsal bone. This modification allows the patient the best possible use of his or her limited dorsiflexion. Should You Consider Surgery?