How To Treat Hallux Rigidus In Runners
Physical therapy offers a reasonable level of hope to the athlete with hallux rigidus who wants to avoid surgery. Just as we have learned with cartilage injuries to the knee, aggressive rehabilitation protocols using muscle reeducation, joint mobilization and flexibility exercises can stabilize a joint and minimize symptoms of degenerative arthritis. Strengthening of the flexor hallucis longus muscle as well as the plantar intrinsic muscles of the feet can improve stability of the first MPJ. A skilled therapist can also mobilize this joint to increase range of motion. All of these measures can be of value to the patient even if he or she ultimately undergoes surgery.
A Closer Look At Surgical Considerations For The Athlete
Surgery designed to relieve the symptoms of hallux rigidus can have one or more intended methods and outcomes. Surgeons may restore articular cartilage via stimulation of local chondrogenic source, transplant autograft tissue. One may perform decompression or realignment of the first MPJ via osteotomy of the first metatarsal or proximal phalanx. Alternately, surgeons may resect the joint surface(s) via arthroplasty with soft tissue interposition or a prosthetic implant, or perform arthrodesis of the first MPJ.
There has been a variety of papers over the last 40 years that have documented positive and negative outcomes of surgical procedures for the treatment of hallux rigidus. Few have focused on the long-term effects of any surgical treatment for running athletes. The majority of patients included in large group studies receiving surgery for hallux rigidus are over the age of 50, overweight and have a sedentary lifestyle. The positive outcome of many surgical procedures performed on these types of patients could not be expected in an athletic patient population.
Why Intraoperative Inspection And Debridement Are Important
With any surgical intervention for hallux rigidus, surgeons should perform an intraoperative inspection and debridement before making any decision about osteotomy, fusion, etc.
Many times, a patient showing significant symptoms of hallux rigidus with minimal radiographic evidence of degenerative joint disease will demonstrate unexpected cartilage loss when one surgically explores the joint. At other times, a rigid joint will suddenly demonstrate over 50 degrees dorsiflexion after simple resection of the osteophytes and freeing of the sesamoid apparatus adhering to the plantar surface of the first metatarsal.
One should perform subchondral drilling on all cartilage defects whether the surgeon opts for osteotomy or a simple cheilectomy. Newer techniques of autograft implantation of osteochondral material obtained from the talus offer promise for the treatment of early stage hallux rigidus. However, no studies have been published showing outcomes with running athletes.
What Studies Reveal About Cheilectomy Procedures For Stage I Or Stage II Hallux Rigidus
One of the few papers documenting long-term outcomes of surgery on high level athletes with hallux rigidus utilized a cheilectomy procedure for relief of symptoms.16 The study authors noted good to excellent results after a five-year follow-up of 20 athletic patients and pedobarographic measurements showed improvements of pressure distribution under the forefoot with less lateral loading of the metatarsals.
The typical cheilectomy involves resection of one-third to one-fourth of the dorsal articular surface of the first metatarsal head. A modification of this involves a Valenti arthroplasty, which is a V-shaped resection of the dorsal half of the head of the first metatarsal and the base of the proximal phalanx. Papers advocating the use of an interpositional arthroplasty involving autograft or allograft tendon material have not studied results with running athletes.
It is important to restore range of motion to at least 50 degrees dorsiflexion intraoperatively. In my experience, approximately 10 to 20 degrees of dorsiflexion noted intraoperatively will be lost in the postoperative period. Therefore, if one desires an end result of 30 degrees dorsiflexion, the surgeon should obtain at least 50 degrees dorsiflexion on the operating table with any type of surgical procedure (other than arthrodesis) for hallux rigidus.