How To Treat Hallux Rigidus In Runners

Doug Richie Jr., DPM

   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.

   The selection of footwear that has maximal stiffness across the forefoot will decrease the dorsiflexion moment directed across the MPJs during running gait. Most running shoes have some degree of flexibility across the forefoot. Therefore, I often direct runners with stage II and greater hallux rigidus to switch to lightweight day hikers and switch from asphalt to dirt trails for long distance running. Yes, these shoes may be too stiff for the average runner but they can facilitate profound relief of jamming of the great toe joint.

What About Medication Or Physical Therapy?

   I do not advocate the use of injectable corticosteroids for athletes with hallux rigidus unless there may be some benefit for short-term relief of symptoms. For the most part, the relief is so temporary that this type of treatment is disappointing. Non-steroidal anti-inflammatories can relieve pain but do not reverse the pathology of hallux rigidus. Pain relief with medication may only mask the degenerative process and could lead to rapid deterioration of the great toe joint in running athletes.

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