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Should We Fuse The Great Toe Joint Of Athletes?

Arthrodesis of the first metatarsophalangeal joint (MPJ) is the “gold standard” for surgical treatment of grade 3 and grade 4 hallux rigidus.1-4 However, there has been a longstanding reluctance to perform this procedure on younger and athletic patients due to concerns about compromise of function and performance.5 As a result, surgeons have often opted for cheilectomy and  interpositional arthroplasty as preferred treatment options for hallux rigidus in the younger athletic patient.6,7 

Recently, Saxena and colleagues reported on the return to activity rate in athletic patients (average age of 49 years) undergoing a modified Valenti interpositional arthroplasty procedure for hallux rigidus.8 Runners and dancers returned to sport at some level by eight weeks post-operatively while soccer players returned at 16 weeks or later. There was no other functional scoring to determine overall outcome or patient satisfaction. The authors noted that their own review of the literature showed no published studies of first MPJ arthrodesis outcomes in younger athletic patients.

Ironically, in the same publication month in which Saxena and coworkers published their study, Da Cunha and colleagues reported on a five-year follow up of 73 patients who had arthrodesis of the first MPJ for hallux rigidus.9 These authors also studied relatively young patients (mean age of 49 years) and their ability to return to sport activities after arthrodesis of their great toe joint.  

This study reflected the fact that most active middle-age patients participate in more than one activity or sport. Pre-operatively, the patients collectively participated in 21 different sports or physical activities. Participation in these activities actually increased after surgery. Patients were highly active after fusion of their first MPJ with one in three spending more than 10 hours per week in physical fitness activities or sports. The remainder spent at least five to 10 hours per week in these pursuits. Prior to surgery and after surgery, patients did not discontinue any physical activities, and actually initiated 21 new activities collectively after the procedure.9

However, the mean return to physical activity after arthrodesis ranged between six to nine months, longer than the period reported by Saxena and colleagues for returning to sport after arthroplasty.8,9

That said, Da Cunha and colleagues did assess physical activity with a validated clinical outcome measure, the Foot and Ankle Outcome Score (FAOS), for hallux rigidus.9,10 All FAOS subscores showed significant improvement from pre- to post-op including pain, activities of daily living, sports and recreation, and quality of life. The sports questionnaire revealed 96 percent patient satisfaction with the results of their surgery.  

Some patients reported increased difficulty with sports postoperatively and an inability to return to their maximal level of participation. The activities that were more difficult postoperatively were yoga, pilates, cross-country skiing and hiking. With these activities, post-op stiffness of the great toe was the major contributor to reduced success. Interestingly, runners achieved a similar or better level of participation after undergoing arthrodesis of the first MPJ. 

This study verifies my own experience performing fusions of the great toe joint in younger athletic patients. Given the choices, arthrodesis has the best chance of eliminating pain and potential for future surgery. Furthermore, fear about participation in sport with fusion of the first MPJ is mostly unfounded. Athletes seem to compensate for this loss of motion both pre-operatively and post-operatively.11,12

Hallux rigidus continues to be a condition for which few good, viable, long-term treatment options exist.1 While new synthetic implant procedures are available, many foot and ankle surgeons are reluctant to implement them in athletic patients.13 There continues to be a growing body of evidence supporting arthrodesis of the first MPJ and this recent study provides some assurance that younger patients can return to sport and fitness activity without long-term sequalae.9 

Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons and the American Academy of Podiatric Sports Medicine. 

References

1.   Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int. 2008;29(6):637-646.

2.  van Doeselaar DJ, Heesterbeek PJC, Louwerens JWK, Swierstra BA. Foot function after fusion of the first metatarsophalangeal joint. Foot Ankle Int. 2010;31(8):670-675.

3.  DeSandis B, Pino A, Levine DS, et al. Functional outcomes following first metatarsophalangeal arthrodesis. Foot Ankle Int. 2016;37(7):715-721.

4.  DeFrino PF, Brodsky JW, Pollo FE, Crenshaw SJ, Beischer AD. First metatarsophalangeal arthrodesis: a clinical, pedobarographic and gait analysis study. Foot Ankle Int. 2002;23(6):496-502.

5.  Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999;31(7suppl):S448-S458.

6.  Feltham GT, Hanks SE, Marcus RE. Age-based outcomes of cheilectomy for the treatment of hallux rigidus. Foot Ankle Int. 2001;22(3):192-197.

7.  Saxena A. Return to activity after foot and ankle surgery: a preliminary report on select procedures. J Foot Ankle Surg. 2000;39:114-119.

8. Saxena A, Valerio DL, Behan SA, Hofer D. Modified Valenti arthroplasty in running and jumping athletes with hallux limitus/rigidus:  a analysis of one hundred procedures. J Foot Ankle Surg. 2019;58(4):609-616.

9. Da Cunha RJ, MacMahon A, Jones MT, et al. Return to sports and physical activities after first metatarsophalangeal joint arthrodesis in young patients. Foot Ankle Int. 2019;40(7):745-752. 

10. Hogan MV, Mani SB, Chan JY, Do H, Deland JT, Ellis SJ. Validation of the foot and ankle outcome score for hallux rigidus. HSS J. 2016;12(1):44-50.

11. Brodsky JW, Baum BS, Pollo FE, Mehta H. Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus. Foot Ankle Int. 2007;28(2):162-165.

12. Brodsky JW, Passmore RN, Pollo FE, Shabat S. Functional outcome of arthrodesis of the first metatarsophalangeal joint using parallel screw fixation. Foot Ankle Int. 2005;26(2):140-146.

13. Hyer C, Baravarian B, Brandão R, Bull PE, Fidler C, Watson BC. Addressing first MPJ arthritis: a roundtable discussion. Podiatry Today. 2019;32(6):22-30.

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