How To Treat Hallux Rigidus In Runners

Doug Richie Jr., DPM

Given the lack of studies that have specifically addressed hallux rigidus in runners, this author reviews the existing literature on the condition, defuses a couple of biomechanical myths and offers salient pointers on a variety of treatment options ranging from orthotic therapy to arthrodesis.

   Perhaps no other condition treated by the podiatric physician is more controversial and more poorly understood than hallux rigidus. Even less understood are the effects of this pathology on the running athlete or the selection of proper treatment interventions that ensure optimal return to athletic performance.

   Accordingly, let us take a closer look at several myths and misunderstandings about the evaluation and treatment of hallux rigidus in running athletes.

   For this article, the definition of a true “athlete” is any individual who runs more than 20 miles per week or participates in vigorous competitive sports such as tennis, racquetball, volleyball or basketball more than two times per week. Running athletes who present with hallux rigidus pose a significant challenge for the treating physician based upon the poor understanding of the biomechanics of this condition as well as a lack of agreement for a standardized treatment protocol.

   While it may be universally accepted that one should initially pursue conservative, non-operative treatment when treating an athlete with hallux rigidus, there may be a lack of consensus on the type of conservative interventions. If you use foot orthotic therapy, what are the casting and prescription criteria? Are corticosteroid injections indicated? What is the role of physical therapy? Are footwear modifications indicated?

   Finally, when conservative measures fail, what are the best surgical options for the running athlete? Are there published studies that document favorable outcomes for the running athlete with hallux rigidus?

Hallux Rigidus: Keys To Definition And Relevant Classification Systems

   Cotterill first coined the term hallux rigidus in 1887.1 Hallux rigidus is now the most universally accepted description of a condition in which there is a combination of restricted range of motion and degenerative arthrosis of the first metatarsophalangeal joint (MPJ). The term “functional hallux limitus,” originally described by Laird, should apply to a separate group of individuals who do not have degenerative changes of their great toe joints.2 However, it is recognized that functional hallux limitus may be one of the etiologic factors of hallux rigidus.

   Various authors have described hallux rigidus as resulting from a myriad of causes including systemic arthrosis, trauma, inflammatory disorders, neuromuscular disorders, congenital abnormality and iatrogenic events. The prevailing thinking is that abnormality in dynamic foot function is the primary etiology of hallux rigidus. However, the true mechanism of dysfunction of the great toe joint during gait remains poorly understood.

   Roukis has written the most insightful and provocative papers on hallux rigidus in the podiatric literature.3-5 In these studies, Roukis demonstrated a clear relationship between hallux equinus and metatarsus primus elevatus in patients with hallux rigidus. What has not been demonstrated is whether these clinical and radiographic measurements were acquired or congenital, or what biomechanical conditions were responsible for the progressive changes in alignment on the medial column of the foot.

   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.

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