How To Treat Hallux Rigidus In Runners

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Author(s): 
Doug Richie Jr., DPM

Conservative Care: Can It Have An Impact For Hallux Rigidus?

   When an athlete initially presents with hallux rigidus, the symptoms are usually significant as this type of patient will put off a visit to the doctor as long as possible. It is suggested that treatment of hallux rigidus on the initial visit be similar to treating any other acute injury in the athlete. One should follow the protocol of PRICE (protection, rest, ice, compression and elevation) to calm down initial symptoms. Often, a brief period of rest from running activities while substituting non-impact cardiovascular training (i.e. bike, elliptical trainer) can allow acute inflammation and swelling to subside so follow-up conservative measures have a better chance of succeeding.

   As I noted previously, many running athletes can participate in their sport with significant clinical evidence of hallux rigidus but have minimal symptoms. By the time they present to the podiatric physician for treatment, their condition may have already advanced to stage III or stage IV. At this point, degenerative changes in the first MPJ are so severe that most non-operative measures will have little hope of success.

   However, bear in mind that running athletes use a smaller range of motion than walkers so small increments of a change of a range of motion may have a more profound benefit in relieving symptoms. The symptoms of hallux rigidus basically derive from either the degenerative arthrosis process, the mechanical jamming of the first MPJ, osteophytic impingement against surrounding soft tissue or footwear. Conservative treatment through the use of foot orthoses, physical therapy or footwear modification can address one or all of these causes of symptoms.

Reviewing The Goals Of Orthotic Therapy In Runners With Hallux Rigidus

   In treating the running athlete with custom functional foot orthoses, one can direct strategies toward one of two opposing functions. Physicians can either improve first ray function and dorsiflexion range of the first MPJ, or block range of motion of the hallux on the first metatarsal.

   In stage I hallux rigidus, a standard orthotic prescription designed to improve subtalar position, locking of the midtarsal joint and stabilization of the first ray during propulsion can be very successful in minimizing symptoms. The foot orthosis casting should utilize a neutral suspension cast, holding the midtarsal joint loaded and fully pronated. Plantarflexing the first ray to end range will maximize position of this segment for optimal first MPJ dorsiflexion.

   When it comes to enhancing plantarflexion of the first metatarsal, it may be beneficial to add to the orthosis with a reverse Morton’s extension or a Kinetic Wedge®. I have also been impressed with the new Cluffy Wedge®, which preloads the plantar fascia to facilitate early engagement of the windlass mechanism around the first MPJ.

   When treating stage II through IV hallux rigidus in runners, the primary goal of foot orthotic therapy or shoe modification should be blocking or shielding the hallux from dorsiflexion at the first metatarsal. An extension of the footplate of the orthotic under the hallux is a simple yet very effective technique to reduce dorsiflexion moment at the first MPJ. The main drawback to this type of device is the bulk of the orthosis plate under the great toe joint as this can compromise shoe fit. If a patient has a prominent exostosis of the first MPJ, the increased bulk of the footplate extension may actually exacerbate symptoms rather than provide relief.

What You Should Know About Footwear Modifications

   An alternative to foot orthotic footplate extensions under the hallux to block motion of the first MPJ is the use of a graphite composite plate inside of the shoe. These plates are available at various degrees of thickness and rigidity, and will fit in a cleated shoe better than a foot orthotic. The response of patients with hallux rigidus to blocking footplates is variable. For the most part, athletic performance is not hampered by the use of these devices.

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