How To Treat Hallux Rigidus In Runners
Pertinent Insights On Arthrodesis For Stage III And IV Hallux Rigidus
What was once a forbidden procedure for the active patient is now becoming the best option for the treatment of stage III and IV hallux rigidus. Out of all retrospective studies of surgical treatment of hallux rigidus, those utilizing arthrodesis of the first MPJ consistently show superior results and patient satisfaction in comparison to other surgical options.19-22
Concerns about fusion of the first MPJ in active individuals focus on alteration of gait mechanics, transfer of dorsiflexion moment to the hallux interphalangeal joint, loss of the windlass mechanism and an inability to wear elevated heel footwear. However, there is minimal evidence in the literature that any of these events actually occur to any significant level.
When it comes to studies of athletes, Bouché showed favorable results in his preliminary study published in 1996.23 Bouché has expanded his study to now include 40 active athletic patients who have achieved good to excellent results with arthrodesis of the first MPJ for painful hallux rigidus.24
Kinematic studies of patients who underwent arthrodesis of the first MPJ showed a significantly shorter step length as well as reduced ankle power and torque at push off.20 At the same time, Lombardi showed increased medial longitudinal arch height after fusion of the first MPJ.19
It is unclear whether the gait abnormalities are the result of fusion or are a long-term compensation of walking with a painful first MPJ that has not changed after surgery. The fact is that athletes who present for treatment of stage III and IV hallux rigidus have functioned with less than 10 degrees range of motion of the first MPJ for many years.
Fusion of this joint likely has little change on gait and compensation at this point. The primary effect of fusion is the elimination of pain, which has demonstrated significant positive patient satisfaction.
Running athletes with hallux rigidus are unique and differ from the typical older sedentary patients who most frequently present with this condition. On one hand, running athletes demand less dorsiflexion range of motion of the first MPJ in comparison to walking patients. Therefore, runners can continue their sport even when dorsiflexion range of motion diminishes to less than 40 degrees. Conversely, running increases internal joint moments in the feet 10-fold, which should be a strong deterrent to the use of prosthetic joint implants that have been designed to relieve the symptoms of hallux rigidus in sedentary patients.
Few studies have evaluated the effectiveness of surgical interventions for the treatment of hallux rigidus in running athletes. While cheilectomy may be beneficial for early stages of hallux rigidus, arthrodesis of the first MPJ appears to be the best option for the relief of symptoms with stage III and stage IV hallux rigidus in active, athletic patients.
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is a Fellow of the American Academy of Podiatric Sports Medicine and is in private practice in Seal Beach, Ca.
For further reading, see “Managing Hallux Rigidus In The Athlete” in the April 2004 issue or “Key Insights In Treating Hallux Limitus” in the March 2007 issue of Podiatry Today.
For reprint information or to access the archives, visit www.podiatrytoday.com.