Managing Hallux Rigidus In The Athlete
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. 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? With progression of the disease process, one will note further proliferation of reactive bone along the dorsal aspect of the joint and degeneration of the dorsal articular surface. If the symptoms are of sufficient magnitude to limit the athlete’s activities, you should consider surgical intervention. There is an array of surgical procedures for treating hallux rigidus. Each procedure can be classified according to the specific area of the MTPJ. Surgery consists of five categories: • remodeling arthroplasty • resection arthroplasty • arthrodesis • replacement arthroplasty • periarticular osteotomy When performing surgery on these athletes, one seeks to increase range of motion, maintain the length of the toe and reduce symptoms. Cheilectomy procedures are often indicated, with resection of at least one-third of the dorsal aspect of the metatarsal head, any osteophytes present at the base of the proximal phalanx and loose bodies. One should avoid implant arthroplasties and fusions in this patient population. Final Notes Although hallux rigidus is a progressive disorder, prophylactic taping of the hallux and modifications to the shoe to stiffen the sole will decrease the repetitive stress placed on the great toe. In addition, you should emphasize exercises to increase dorsiflexion in the athlete who has limited motion of the first MTPJ. Dr. Caselli is an Adjunct Professor in the Department of Orthopedic Services at the New York College of Podiatric Medicine. He is also a staff podiatrist at the VA Hudson Valley Health Care System.
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