Current And Emerging Techniques For Hallux Rigidus

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Author(s): 
Brent D. Haverstock, DPM, FACFAS

   Other forms of diagnostic imaging are usually not required. However, on occasion, one can utilize a CT scan to determine if there is an osteochondral lesion in an early-stage hallux rigidus deformity.8,9

   There are a number of classification or grading systems that utilize both biomechanical features and X-ray criteria to stage hallux rigidus. The most useful classification system for hallux rigidus was suggested by Roukis and Jacobs, and combines criteria from the systems proposed by Drago and Oloff, Hanft and Mason and Kravitz and colleagues.10-13 The classification described by Roukis and Jacobs combines grades according to a four-stage hybrid hallux rigidus radiographic grading system.13

Can Conservative Care Have An Impact For Hallux Rigidus?

Non-operative management is still the mainstay of treatment for hallux rigidus with studies demonstrating a 50 percent success rate.14

   The pain and lack of dorsiflexion associated with hallux rigidus makes ambulation and propulsion difficult. Custom foot orthotics with a first ray extension will limit dorsiflexion of the first metatarsophalangeal joint. Having the patient wear a stiff soled shoe or fitting a carbon graphite gait plate under the shoe’s insole will eliminate the need for dorsiflexion at the first MPJ. Other modifications to footwear can include a forefoot rocker or shoes that are fabricated with a natural forefoot rocker. One may utilize a deep toe box to eliminate pressure on the dorsal prominence.15,16 Medical options include the use of oral and topical non-steroidal anti-inflammatories and intra-articular cortisone injections.17

   Researchers have discussed the use of viscosupplementation in the management of symptomatic hallux rigidus. In a study to evaluate the effectiveness of a single intra-articular injection of hylan G-F 20 (Synvisc, Genzyme) for first MPJ osteoarthritis, researchers in Australia assessed 151 patients who received up to a 1 mL intra-articular injection of either hylan G-F 20 or a placebo (saline).18 The study authors found no statistically significant differences in foot pain (as measured by the Foot Health Status Questionnaire) between the groups at three months. They noted few statistically significant differences in the secondary outcome measures including first MPJ pain and stiffness, first MPJ dorsiflexion range of motion, hallux plantarflexion strength and changes in plantar pressures. They also noted no significant difference in adverse effects. Accordingly, the study authors concluded that an intra-articular injection of hylan G-F 20 was no more effective than placebo in reducing symptoms in people with symptomatic first MPJ osteoarthritis.

   For the management of hallux rigidus, clinicians may utilize physiotherapy consisting of a comprehensive intervention program that includes great toe mobilization, flexor hallucis longus and brevis strengthening and sesamoid mobilization.19 Researchers have also demonstrated that chiropractic manipulation provides symptomatic relief with regular manipulation and joint range of motion.20

What The Literature Reveals About Surgical Procedures For Hallux Rigidus

Hallux rigidus by its very nature is a complex disorder with various authors describing numerous surgical procedures for management of the disorder. The goal of surgical management is to eliminate pain.

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