Managing Hallux Rigidus In The Athlete

Author(s): 
By Mark A. Caselli, DPM

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.




References:

References

1. Abdo RV: Rehabilitation of baseball injuries. In Sammarco GJ (ed), Rehabilitation of the Foot and Ankle, Mosby, St. Lewis, 1995.

2. Caselli MA, George DH: Foot deformities: biomechanical and pathomechanical changes associated with aging, part I. Clin Podiatr Med Surg 20(2003) 487-509

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