Managing Hallux Rigidus In The Athlete

Author(s): 
By Mark A. Caselli, DPM

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. 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

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