How To Treat Hallux Rigidus In Runners
- Volume 22 - Issue 4 - April 2009
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There have been many classification systems relevant to hallux rigidus. In a recently published in-depth analysis of these systems, Beeson et al., demonstrated universal shortcomings and the need for valid and reliable criteria.6 Without reliable, objective measures of range of motion of the first MPJ joint and sound criteria for the measurement of degenerative changes using traditional imaging techniques, it will not be possible to develop treatment protocols that can have reliable outcomes.
Notwithstanding, Roukis, et al., have proposed a classification system, which is actually a hybrid of the systems proposed by Drago, Hanft and Kravitz.3,7-9 This system appears to be most useful in the evaluation of the patient with hallux rigidus. (See “A Guide To Radiographic Grading Of Hallux Rigidus” on page 54.) In terms of running athletes, there is no existing classification system that takes into account the level of activity of the patient, the amount of pain and disability during exercise, or the footwear requirements of the sport. For example, moderate osteophytic spurring may be asymptomatic in the sedentary patient wearing roomy oxford shoes but this can become severely painful for an athlete wearing soccer cleats.
Most classification systems for hallux rigidus do not provide objective criteria for measuring range of motion of the first MPJ joint. Furthermore, there is significant misunderstanding of what is considered “normal” range of motion of the great toe joint, whether one is assessing this with the patient in a non-weightbearing position or during walking and running gait.
Reassessing The Normal Range Of Motion For The First MPJ
Nearly every podiatric physician assumes the normal dorsiflexion range of motion of the first MPJ is at least 65 degrees. One reason is the universally accepted proposal by Root, Weed and Orien, who demonstrated in a theoretical model that 65 degrees of dorsiflexion demand would be required of the hallux on the first metatarsal if normal hip, knee and ankle flexion occurred during the propulsive phase of gait.10
Since the work of Root, et al., was published, many other authors (Joseph, Buell, Bojsen-Moller, Hetherington) speculated or measured “normal” ranges of motion of the first MPJ, which ranged between 65 and 100 degrees of dorsiflexion.11-13 Further scrutiny reveals that many of these studies confuse non-weightbearing measurements of range of motion of the great toe joint with actual measurements obtained during gait. In reality, until recently, no accurate methodology existed to measure motion of the first MPJ in gait.
Do Non-Weightbearing Measurements Correlate With Actual Gait?
Until recently, measuring range of motion of bone segments within the foot was not possible. Today, studies of measurements of multi-segment foot models are being published regularly and represent the most exciting research of lower extremity function. These studies have already challenged many previously held notions about the movement of bones in the human foot during gait.
In 1999, Nawoczenski, et al., published a study of motion of the first MPJ in 10 healthy people during walking gait.14 They used an electromagnetic tracking device to accurately measure motion of the hallux relative to the first metatarsal during the entire stance phase of gait.
Nawoczenski, et al., also studied different clinical tests to determine which measure would most accurately predict the actual range of motion patients would utilize in their great toe joint during gait. These tests included: passive dorsiflexion (non-weightbearing); active dorsiflexion (non-weightbearing); passive dorsiflexion (weightbearing); active dorsiflexion (weightbearing); and active dorsiflexion during heel raise.